Outpatient Parenteral Antimicrobial Therapy in a Safety Net Hospital: Opportunities for Improvement

Background

Outpatient parenteral antimicrobial therapy (OPAT) is a safe and cost-effective transitional care approach administered via different delivery models. No standards exist for appropriate OPAT program staffing. We examined outcomes of patients receiving OPAT via different care models to identify strategies to improve safety while reducing health care overuse.

Methods

Retrospective demographic, clinical, and outcome data of patients discharged with OPAT were reviewed in 2 periods (April-June 2021 and January-March 2022; ie, when staffing changed) and stratified by care model: self-administered OPAT, health care OPAT, and skilled nursing facility OPAT.

Results

Of 342 patients, 186 (54%) received OPAT in 2021 and 156 (46%) in 2022. Hospital length of stay rose from 12.4 days to 14.3 in 2022. In a Cox proportional hazards regression model, visits to the emergency department (ED) within 30 days of OPAT initiation (hazard ratio, 1.76; 95% CI, 1.13-2.73; P = .01) and readmissions (hazard ratio, 2.34; 95% CI, 1.22-4.49; P = .01) increased in 2022 vs 2021, corresponding to decreases in OPAT team staffing. Higher readmissions in the 2022 cohort were for reasons unrelated to OPAT (P = .01) while readmissions related to OPAT did not increase (P = .08).

Conclusions

In a well-established OPAT program, greater health care utilization-length of stay, ED visits, and readmissions-were seen during periods of higher staff turnover and attrition. Rather than blunt metrics such as ED visits and readmissions, which are influenced by multiple factors besides OPAT, our findings suggest the need to develop OPAT-specific outcome measures as a quality assessment tool and to establish optimal OPAT program staffing ratios.

Examining barriers to implementing a surgical-site infection bundle

BACKGROUND

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

OBJECTIVE

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

DESIGN

Qualitative study.

METHODS

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

SETTING

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

PARTICIPANTS

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

RESULTS

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.

CONCLUSIONS

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.

Introduction to A Compendium of Strategies to Prevent Healthcare-Associated Infections In Acute-Care Hospitals: 2022 Updates

Since the initial publication of A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals in 2008, the prevention of healthcare-associated infections (HAIs) has continued to be a national priority. Progress in healthcare epidemiology, infection prevention, antimicrobial stewardship, and implementation science research has led to improvements in our understanding of effective strategies for HAI prevention. Despite these advances, HAIs continue to affect ∼1 of every 31 hospitalized patients, leading to substantial morbidity, mortality, and excess healthcare expenditures, and persistent gaps remain between what is recommended and what is practiced.The widespread impact of the coronavirus disease 2019 (COVID-19) pandemic on HAI outcomes in acute-care hospitals has further highlighted the essential role of infection prevention programs and the critical importance of prioritizing efforts that can be sustained even in the face of resource requirements from COVID-19 and future infectious diseases crises.The Compendium: 2022 Updates document provides acute-care hospitals with up-to-date, practical expert guidance to assist in prioritizing and implementing HAI prevention efforts. It is the product of a highly collaborative effort led by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Disease Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of organizations and societies with content expertise, including the Centers for Disease Control and Prevention (CDC), the Pediatric Infectious Disease Society (PIDS), the Society for Critical Care Medicine (SCCM), the Society for Hospital Medicine (SHM), the Surgical Infection Society (SIS), and others.

Is there an association between peri-diagnostic vaccination and clinical outcomes in COVID-19 patients?

Background

Peri-diagnostic vaccination contemporaneous with SARS-CoV-2 infection might boost antiviral immunity and improve patient outcomes. We investigated, among previously unvaccinated patients, whether vaccination (with the Pfizer, Moderna, or J&J vaccines) during the week before or after a positive COVID-19 test was associated with altered 30-day patient outcomes.

Methods

Using a deidentified longitudinal EHR repository, we selected all previously unvaccinated adults who initially tested positive for SARS-CoV-2 between December 11, 2020 (the date of vaccine emergency use approval) and December 19, 2021. We assessed whether vaccination between days -7 and +7 of a positive test affected outcomes. The primary measure was progression to a more severe disease outcome within 30 days of diagnosis using the following hierarchy: hospitalization, intensive care, or death.

Results

Among 60,031 hospitalized patients, 543 (0.91%) were initially vaccinated at the time of diagnosis and 59,488 (99.09%) remained unvaccinated during the period of interest. Among 316,337 nonhospitalized patients, 2,844 (0.90%) were initially vaccinated and 313,493 (99.1%) remained unvaccinated. In both analyses, individuals receiving vaccines were older, more often located in the northeast, more commonly insured by Medicare, and more burdened by comorbidities. Among previously unvaccinated patients, there was no association between receiving an initial vaccine dose between days -7 and +7 of diagnosis and progression to more severe disease within 30 days compared to patients who did not receive vaccines.

Conclusions

Immunization during acute SARS-CoV-2 infection does not appear associated with clinical progression during the acute infectious period.

Risk Factors for SARS-CoV-2 Infection and Severe Outcomes Among People With Human Immunodeficiency Virus: Cohort Study

Background

Studies on COVID-19 in people with HIV (PWH) have had limitations. Further investigations on risk factors and outcomes of SARS-CoV-2 infection among PWH are needed.

Methods

This retrospective cohort study leveraged the national OPTUM COVID-19 data set to investigate factors associated with SARS-CoV-2 positivity among PWH and risk factors for severe outcomes, including hospitalization, intensive care unit stays, and death. A subset analysis was conducted to examine HIV-specific variables. Multiple variable logistic regression was used to adjust for covariates.

Results

Of 43 173 PWH included in this study, 6472 had a positive SARS-CoV-2 result based on a polymerase chain reaction test or antigen test. For PWH with SARS-CoV-2 positivity, higher odds were found for those who were younger (18-49 years), Hispanic White, African American, from the US South, uninsured, and a noncurrent smoker and had a higher body mass index and higher Charlson Comorbidity Index. For PWH with severe outcomes, higher odds were identified for those who were SARS-CoV-2 positive, older, from the US South, receiving Medicaid/Medicare or uninsured, a current smoker, and underweight and had a higher Charlson Comorbidity Index. In a subset analysis including PWH with HIV care variables (n = 5098), those with unsuppressed HIV viral load, a low CD4 count, and no antiretroviral therapy had higher odds of severe outcomes.

Conclusions

This large US study found significant ethnic, racial, and geographic differences in SARS-CoV-2 infection among PWH. Chronic comorbidities, older age, lower body mass index, and smoking were associated with severe outcomes among PWH during the COVID-19 pandemic. SARS-CoV-2 infection was associated with severe outcomes, but once we adjusted for HIV care variables, SARS-CoV-2 was no longer significant; however, low CD4 count, high viral load, and lack of antiretroviral therapy had higher odds of severe outcomes.

Public perception of COVID-19 vaccines through analysis of Twitter content and users

BACKGROUND

With the global continuation of the COVID-19 pandemic, the large-scale administration of a SARS-CoV-2 vaccine is crucial to achieve herd immunity and curtail further spread of the virus, but success is contingent on public understanding and vaccine uptake. We aim to understand public perception about vaccines for COVID-19 through the wide-scale, organic discussion on Twitter.

METHODS

This cross-sectional observational study included Twitter posts matching the search criteria (('covid*' OR 'coronavirus') AND 'vaccine') posted during vaccine development from February 1st through December 11th, 2020. These COVID-19 vaccine related posts were analyzed with topic modeling, sentiment and emotion analysis, and demographic inference of users to provide insight into the evolution of public attitudes throughout the study period.

FINDINGS

We evaluated 2,287,344 English tweets from 948,666 user accounts. Individuals represented 87.9 % (n = 834,224) of user accounts. Of individuals, men (n = 560,824) outnumbered women (n = 273,400) by 2:1 and 39.5 % (n = 329,776) of individuals were ≥40 years old. Daily mean sentiment fluctuated congruent with news events, but overall trended positively. Trust, anticipation, and fear were the three most predominant emotions; while fear was the most predominant emotion early in the study period, trust outpaced fear from April 2020 onward. Fear was more prevalent in tweets by individuals (26.3 % vs. organizations 19.4 %; p < 0.001), specifically among women (28.4 % vs. males 25.4 %; p < 0.001). Multiple topics had a monthly trend towards more positive sentiment. Tweets comparing COVID-19 to the influenza vaccine had strongly negative early sentiment but improved over time.

INTERPRETATION

This study successfully explores sentiment, emotion, topics, and user demographics to elucidate important trends in public perception about COVID-19 vaccines. While public perception trended positively over the study period, some trends, especially within certain topic and demographic clusters, are concerning for COVID-19 vaccine hesitancy. These insights can provide targets for educational interventions and opportunity for continued real-time monitoring.

Severe Mpox Infections in People With Uncontrolled Human Immunodeficiency Virus

In the current mpox outbreak, infections are usually self-limited. We describe 3 patients with uncontrolled HIV and mpox infections lasting months, causing debilitating lesions, complications, and death, despite initiating anti-mpox and antiretroviral therapy. Delayed treatment of mpox with antiviral agents may contribute to poor outcomes in severely immunocompromised patients.

Incidence and Risk Factors for Severe Outcomes in Pediatric Patients With COVID-19

OBJECTIVES

Throughout the pandemic, children with COVID-19 have experienced hospitalization, ICU admission, invasive respiratory support, and death. Using a multisite, national dataset, we investigate risk factors associated with these outcomes in children with COVID-19.

METHODS

Our data source (Optum deidentified COVID-19 Electronic Health Record Dataset) included children aged 0 to 18 years testing positive for COVID-19 between January 1, 2020, and January 20, 2022. Using ordinal logistic regression, we identified factors associated with an ordinal outcome scale: nonhospitalization, hospitalization, or a severe composite outcome (ICU, intensive respiratory support, death). To contrast hospitalization for COVID-19 and incidental positivity on hospitalization, we secondarily identified patient factors associated with hospitalizations with a primary diagnosis of COVID-19.

RESULTS

In 165 437 children with COVID-19, 3087 (1.8%) were hospitalized without complication, 2954 (1.8%) experienced ICU admission and/or intensive respiratory support, and 31 (0.02%) died. We grouped patients by age: 0 to 4 years old (35 088), and 5 to 11 years old (75 574), 12 to 18 years old (54 775). Factors positively associated with worse outcomes were preexisting comorbidities and residency in the Southern United States. In 0- to 4-year-old children, there was a nonlinear association between age and worse outcomes, with worse outcomes in 0- to 2-year-old children. In 5- to 18-year-old patients, vaccination was protective. Findings were similar in our secondary analysis of hospitalizations with a primary diagnosis of COVID-19, though region effects were no longer observed.

CONCLUSIONS

Among children with COVID-19, preexisting comorbidities and residency in the Southern United States were positively associated with worse outcomes, whereas vaccination was negatively associated. Our study population was highly insured; future studies should evaluate underinsured populations to confirm generalizability.

Analyzing an Emerging Pandemic on Twitter: Monkeypox

Background

Social media platforms like Twitter provide important insights into the public's perceptions of global outbreaks like monkeypox. By analyzing tweets, we aimed to identify public knowledge and opinions on the monkeypox virus and related public health issues.

Methods

We analyzed English-language tweets using the keyword "monkeypox" from 1 May to 23 July 2022. We reported gender, ethnicity, and race of Twitter users and analyzed tweets to identify predominant sentiment and emotions. We performed topic modeling and compared cohorts of users who self-identify as LGBTQ+ (an abreviation for lesbian, gay, bisexual, transgender, queer, and/or questioning) allies versus users who do not, and cohorts identified as "bots" versus humans.

Results

A total of 48 330 tweets were written by LGBTQ+ self-identified advocates or allies. The mean sentiment score for all tweets was -0.413 on a -4 to +4 scale. Negative tweets comprised 39% of tweets. The most common emotions expressed were fear and sadness. Topic modeling identified unique topics among the 4 cohorts analyzed.

Conclusions

The spread of mis- and disinformation about monkeypox was common in our tweet library. Various conspiracy theories about the origins of monkeypox, its relationship to global economic concerns, and homophobic and racial comments were common. Conversely, many other tweets helped to provide information about monkeypox vaccines, disease symptoms, and prevention methods. Discussion of rising monkeypox case numbers globally was also a large aspect of the conversation.

Conclusions

We demonstrated that Twitter is an effective means of tracking sentiment about public healthcare issues. We gained insight into a subset of people, self-identified LGBTQ+ allies, who were more affected by monkeypox.

Safety and Efficacy of Ceftriaxone in the Treatment of Methicillin-Susceptible Staphylococcus aureus Bloodstream Infections: A Noninferiority Retrospective Cohort Study

BACKGROUND

Antistaphylococcal penicillins and cefazolin are the treatments of choice for methicillin-susceptible Staphylococcus aureus (MSSA) infections, requiring multiple doses daily. At Parkland, eligible uninsured patients with MSSA bloodstream infections (BSI) receive self-administered outpatient parenteral antimicrobial therapy (S-OPAT). Ceftriaxone was used in a cohort of S-OPAT patients for ease of once-daily dosing.

OBJECTIVE

A retrospective study was conducted to evaluate clinical outcomes for patients discharged with ceftriaxone versus cefazolin to treat MSSA BSI.

METHODS

A retrospective cohort noninferiority study design was used to assess treatment efficacy of ceftriaxone versus cefazolin among Parkland S-OPAT patients treated from April 2012 to March 2020. Demographic, clinical, and treatment-related adverse events data were collected. Clinical outcomes included treatment failure as defined by repeat positive blood culture or retreatment within 6 months, all-cause 30-day readmission rates, and central line-associated bloodstream infection (CLABSI) rates.

RESULTS

Of 368 S-OPAT patients with MSSA BSI, 286 (77.7%) received cefazolin, and 82 (22.3%) received ceftriaxone. Demographics and comorbidities were similar for both groups. There were no treatment failures in the ceftriaxone group compared with 4 (1%) in the cefazolin group (P = 0.58). No difference in 30-day readmission rate between groups was found. The CLABSI rates were lower in ceftriaxone group (2%) compared with cefazolin (11%; P = 0.02). Limitations include retrospective cohort design.

CONCLUSIONS

Ceftriaxone was found to be noninferior to cefazolin in this study. Our findings suggest that ceftriaxone is a safe and effective treatment of MSSA BSI secondary to osteoarticular or skin and soft tissue infections when used in the S-OPAT setting.

POSTER ABSTRACT

OFID on 2018 Nov; 5(Suppl 1): S316: doi: 10.1093/ofid/ofy210.894.

Preschool-Aged Household Contacts as a Risk Factor for Viral Respiratory Infections in Healthcare Personnel

Background

Viral respiratory infections (VRIs) are common and are occupational risks for healthcare personnel (HCP). VRIs can also be acquired at home and other settings among HCPs. We sought to determine if preschool-aged household contacts are a risk factor for VRIs among HCPs working in outpatient settings.

Methods

We conducted a secondary analysis of data from a cluster randomized trial at 7 medical centers in the United States over 4 influenza seasons from 2011-2012 to 2014-2015. Adult HCPs who routinely came within 6 feet of patients with respiratory infections were included. Participants were tested for respiratory viruses whenever symptomatic and at 2 random times each season when asymptomatic. The exposure of interest was the number of household contacts 0-5 years old (preschool-aged) at the beginning of each HCP-season. The primary outcome was the rate of polymerase chain reaction-detected VRIs, regardless of symptoms. The VRI incidence rate ratio (IRR) was calculated using a mixed-effects Poisson regression model that accounted for clustering at the clinic level.

Results

Among the 4476 HCP-seasons, most HCPs were female (85.4%) and between 30 and 49 years of age (54.6%). The overall VRI rate was 2.04 per 100 person-weeks. In the adjusted analysis, HCPs having 1 (IRR, 1.22 [95% confidence interval {CI}, 1.05-1.43]) and ≥2 (IRR, 1.35 [95% CI, 1.09-1.67]) preschool-aged household contacts had higher VRI rates than those with zero preschool-aged household contacts.

Conclusions

Preschool-aged household contacts are a risk factor for developing VRIs among HCPs working in outpatient settings.

2357. Risk Factors for COVID-19 Infection and Outcomes in People Living with HIV

Background

As the risk for concomitant COVID-19 infection in people living with HIV (PLHIV) remains largely unknown, we explored a large national database to identify risk factors for COVID-19 infection among PLHIV.

Methods

Using the COVID-19 OPTUM de-identified national multicenter database, we identified 29,393 PLHIV with either a positive HIV test or documented HIV ICD9/10 codes. Using a multiple logistic regression model, we compared risk factors among PLHIV, who tested positive for COVID-19 (5,134) and those who tested negative (24,259) from January 20, 2020, to January 20, 2022. We then compared secondary outcomes including hospitalization, Intensive Care Unit (ICU) stay, and death within 30 days of test among the 2 cohorts, adjusting for COVID-19 positivity and covariates. We adjusted all models for the following covariates: age, gender, race, ethnicity, U.S. region, insurance type, adjusted Charlson Comorbidity Index (CCI), Body Mass Index (BMI), and smoking status.

Results

Among PLHIV, factors associated with higher odds for acquiring COVID-19 (Figure 1) included lower age (compared to age group 18–49, age groups 50–64 and >65 were associated with odds ratios (OR) of 0.8 and 0.75, P= 0.001), female gender (compared to males, OR 1.06, P= 0.07), Hispanic White ethnicity/race (OR 2.75, P= 0.001), Asian (OR 1.35, P= 0.04), and African American (OR 1.23, P= 0.001) [compared to non-Hispanic White], living in the U.S. South (compared to the Northeast, OR 2.18, P= 0.001), being uninsured (compared to commercial insurance, OR 1.46, P= 0.001), higher CCI (OR 1.025, P= 0.001), higher BMI category (compared to having BMI< 30, Obesity category 1 or 2, OR 1.2 and obesity category 3, OR 1.34, P= 0.001), and noncurrent smoking status (compared to current smoker, OR 1.46, P= 0.001). Compared to PLHIV who tested negative for COVID-19, PLHIV who tested positive, had an OR 1.01 for hospitalization (P = 0.79), 1.03 for ICU stay (P=0.73), and 1.47 for death (P=0.001).

Conclusion

Our study found that among PLHIV, being Hispanic, living in the South, lacking insurance, having higher BMI, and higher CCI scores were associated with increased odds of testing positive for COVID-19. PLHIV who tested positive for COVID-19 had higher odds of death.

Disclosures

Christoph U. Lehmann, MD, Celanese: Stocks/Bonds|Markel: Stocks/Bonds|Springer: Honoraria|UTSW: Employee Jeremy Y. Chow, M.D., M.S., Gilead Sciences: Grant/Research Support.

2298. Clinical and Demographic Characteristics of COVID-19 in Pediatric Patients in the United States

Background

The percentage of children infected with COVID-19 has outpaced that of adults. As children &gt;5 years are now eligible to receive vaccines, it is necessary to understand the effect of vaccination in the context of demographic characteristics, clinical factors, and variants on pediatric COVID-19 illness severity.

Methods

We conducted a descriptive study of patients ≤18 years from the Optum® COVID-19 electronic health record dataset. Patients were included if positive for COVID-19 by polymerase chain reaction or antigen testing for the first time from 3/12/2020 to 1/20/2022. We compare race and ethnicity, age, gender, US region of residence, vaccination status, body mass index (BMI), pediatric comorbidity index (PCI) (Sun, Am. J. Epidemiol. 2021), and predominant variant (by time and region) with 2-tailed t-test, multi-category chi-square test, and odds ratios (R version 4.1.2; α = 0.05). PCI is a validated comorbidity index predicting hospitalization in pediatric patients.

Results

Of all pediatric patients in our dataset, 165,468 (13.2%) tested positive for COVID-19. 3,087 (1.9%) were hospitalized, 1,417 (0.9%) were admitted to the ICU, 1545 (0.9%) received respiratory support, and 31 (0.02%) died, comparable to AAP-reported hospitalization and mortality rates in US children. Patients with severe outcomes were more likely to be younger, non-Caucasian, from the US South, unvaccinated, and have a higher PCI (Figure 1). Excluding non-severe outcomes, rates of death and ICU admission were higher in 0–4-year-olds compared to 5–11 or 12–18-year-olds (Figure 2). All patients receiving at least one dose of the vaccine survived. The odds ratio of a severe outcome is 0.11 (95% CI 0.07–0.16) in fully vaccinated patients compared to unvaccinated patients. The odds ratio of a severe outcome is 0.55 (95% CI 0.49–0.63) in partially vaccinated patients compared to unvaccinated patients.

Demographic and clinical characteristics of pediatric patients with COVID-19

Relative proportion of clinically severe outcomes within age groups, excluding non-severe outcomes

Conclusion

In this large population, incidence rate of severe outcomes from COVID-19 in pediatric patients was higher among non-Caucasian patients, living in the South, with underlying comorbid illness, and those not yet eligible for vaccination. These findings reinforce the need for a vaccine for younger patients and targeted vaccine outreach to racial and ethnic minorities and children with chronic conditions.

Disclosures

Christoph U. Lehmann, MD, Celanese: Stocks/Bonds|Markel: Stocks/Bonds|Springer: Honoraria|UTSW: Employee.

Severe Monkeypox in Hospitalized Patients - United States, August 10-October 10, 2022

As of October 21, 2022, a total of 27,884 monkeypox cases (confirmed and probable) have been reported in the United States.§ Gay, bisexual, and other men who have sex with men have constituted a majority of cases, and persons with HIV infection and those from racial and ethnic minority groups have been disproportionately affected (1,2). During previous monkeypox outbreaks, severe manifestations of disease and poor outcomes have been reported among persons with HIV infection, particularly those with AIDS (3-5). This report summarizes findings from CDC clinical consultations provided for 57 patients aged ≥18 years who were hospitalized with severe manifestations of monkeypox¶ during August 10-October 10, 2022, and highlights three clinically representative cases. Overall, 47 (82%) patients had HIV infection, four (9%) of whom were receiving antiretroviral therapy (ART) before monkeypox diagnosis. Most patients were male (95%) and 68% were non-Hispanic Black (Black). Overall, 17 (30%) patients received intensive care unit (ICU)-level care, and 12 (21%) have died. As of this report, monkeypox was a cause of death or contributing factor in five of these deaths; six deaths remain under investigation to determine whether monkeypox was a causal or contributing factor; and in one death, monkeypox was not a cause or contributing factor.** Health care providers and public health professionals should be aware that severe morbidity and mortality associated with monkeypox have been observed during the current outbreak in the United States (6,7), particularly among highly immunocompromised persons. Providers should test all sexually active patients with suspected monkeypox for HIV at the time of monkeypox testing unless a patient is already known to have HIV infection. Providers should consider early commencement and extended duration of monkeypox-directed therapy†† in highly immunocompromised patients with suspected or laboratory-diagnosed monkeypox.§§ Engaging all persons with HIV in sustained care remains a critical public health priority.

District-Level Universal Masking Policies and COVID-19 Incidence During the First 8 Weeks of School in Texas

Texas discontinued state-sponsored business restrictions and mask mandates on March 10, 2021, and mandated that no government officials, including public school officials, may implement mask requirements even in areas where COVID-19 hospitalizations comprised more than 15% of hospitalizations. Nonetheless, some public school districts began the 2021-2022 school year with mask mandates in place. We used quasi-experimental methods to analyze the impact of school mask mandates, which appear to have resulted in approximately 40 fewer student cases per week in the first eight weeks of school. (Am J Public Health. Published online ahead of print May 2, 2022: e1-e5. https://doi.org/10.2105/AJPH.2022.306769).

Outpatient healthcare personnel knowledge and attitudes towards infection prevention measures for protection from respiratory infections

BACKGROUND

Healthcare personnel (HCP) knowledge and attitudes toward infection control measures are important determinants of practices that can protect them from transmission of infectious diseases.

METHODS

Healthcare personnel were recruited from Emergency Departments and outpatient clinics at seven sites. They completed knowledge surveys at the beginning and attitude surveys at the beginning and end of each season of participation. Attitudes toward infection prevention and control measures, especially medical masks and N95 respirators, were compared. The proportion of participants who correctly identified all components of an infection control bundle for seven clinical scenarios was calculated.

RESULTS

The proportion of participants in the medical mask group who reported at least one reason to avoid using medical masks fell from 88.5% on the pre-season survey to 39.6% on the post-season survey (odds ratio [OR] for preseason vs. postseason 0.11, 95% CI 0.10-0.14). Among those wearing N95 respirators, the proportion fell from 87.9% to 53.6% (OR 0.24, 95% CI 0.21-0.28). Participants correctly identified all components of the infection control bundle for 4.9% to 38.5% of scenarios.

CONCLUSIONS

Attitudes toward medical masks and N95 respirators improved significantly between the beginning and end of each season. The proportion of HCP who correctly identified the infection control precautions needed for clinical scenarios was low, but it improved over successive years of participation in the study.

To Test or Not to Test: COVID-19 Prevention Strategies to Keep Large Gatherings Safe

Llibre and colleagues' brief research report investigated the effect of point-of-care onsite testing, use of face masks, and improved ventilation in preventing SARS-CoV-2 transmission at a large indoor concert. The editorialists evaluate factors that contributed to the success of these multimethod prevention strategies and the cost-effectiveness of such measures. They also consider how these measures could be adapted to prevent SARS-CoV-2 transmission in other settings.

Influence of Pre-Season Antibodies against Influenza Virus on Risk of Influenza Infection among Health Care Personnel

BACKGROUND

The association of hemagglutination inhibition (HAI) antibodies with protection from influenza among healthcare personnel (HCP) with occupational exposure to influenza viruses has not been well-described.

METHODS

The Respiratory Protection Effectiveness Clinical Trial was a cluster-randomized, multi-site study that compared medical masks to N95 respirators in preventing viral respiratory infections among HCP in outpatient healthcare settings for 5,180 participant-seasons. Serum HAI antibody titers before each influenza season and influenza virus infection confirmed by polymerase chain reaction were studied over four study years.

RESULTS

In univariate models, the risk of influenza A(H3N2) and B virus infections was associated with HAI titers to each virus, study year, and site. HAI titers were strongly associated with vaccination. Within multivariate models, each log base 2 increase in titer was associated with 15%, 26% and 33-35% reductions in the hazard of influenza A(H3N2), A(H1N1) and B infections, respectively. Best models included pre-season antibody titers and study year, but not other variables.

CONCLUSIONS

HAI titers were associated with protection from influenza among HCP with routine exposure to patients with respiratory illness and influenza season contributed to risk. HCP can be reassured about receiving influenza vaccination to stimulate immunity.

Outbreaks in Health Care Settings

Outbreaks and pseudo-outbreaks in health care settings are complex and should be evaluated systematically using epidemiologic and molecular tools. Outbreaks result from failures of infection prevention practices, inadequate staffing, and undertrained or overcommitted health care personnel. Contaminated hands, equipment, supplies, water, ventilation systems, and environment may also contribute. Neonatal intensive care, endoscopy, oncology, and transplant units are areas at particular risk. Procedures, such as bronchoscopy and endoscopy, are sources of infection when cleaning and disinfection processes are inadequate. New types of equipment can be introduced and lead to contamination or equipment and medications can be contaminated at the manufacturing source.

Transmission of Antimicrobial-Resistant Staphylococcus aureus Clonal Complex 9 between Pigs and Humans, United States

Transmission of livestock-associated Staphylococcus aureus clonal complex 9 (LA-SA CC9) between pigs raised on industrial hog operations (IHOs) and humans in the United States is poorly understood. We analyzed whole-genome sequences from 32 international S. aureus CC9 isolates and 49 LA-SA CC9 isolates from IHO pigs and humans who work on or live near IHOs in 10 pig-producing counties in North Carolina, USA. Bioinformatic analysis of sequence data from the 81 isolates demonstrated 3 major LA-SA CC9 clades. North Carolina isolates all fell within a single clade (C3). High-resolution phylogenetic analysis of C3 revealed 2 subclades of intermingled IHO pig and human isolates differing by 0–34 single-nucleotide polymorphisms. Our findings suggest that LA-SA CC9 from pigs and humans share a common source and provide evidence of transmission of antimicrobial-resistant LA-SA CC9 between IHO pigs and humans who work on or live near IHOs in North Carolina.

Take-home kits to detect respiratory viruses among healthcare personnel: Lessons learned from a cluster randomized clinical trial

BACKGROUND

Health care personnel (HCP) working in outpatient settings routinely interact with patients with acute respiratory illnesses. Absenteeism following symptom development and lack of staff trained to obtain samples limit efforts to identify pathogens among infected HCP.

METHODS

The Respiratory Protection Effectiveness Clinical Trial assessed respiratory infection incidence among HCP between 2011 and 2015. Research assistants obtained anterior nasal and oropharyngeal swabs from HCP in the workplace following development of respiratory illness symptoms and randomly while asymptomatic. Participants received take-home kits to self-collect swabs when absent from work. Samples mailed to a central laboratory were tested for respiratory viruses by reverse transcription polymerase chain reaction.

RESULTS

Among 2,862 participants, 3,467 swabs were obtained from symptomatic participants. Among symptomatic HCP, respiratory virus was detected in 904 of 3,467 (26.1%) samples. Self-collected samples by symptomatic HCP at home had higher rates of viral detection (40.3%) compared to 24% obtained by trained research assistants in the workplace (P < .001).

CONCLUSIONS

In this randomized clinical trial, take-home kits were an easily implemented, effective method to self-collect samples by HCP. Other studies have previously shown relative equivalence of self-collected samples to those obtained by trained healthcare workers. Take-home kit self-collection could diminish workforce exposures and decrease the demand for personnel protective equipment worn to protect workers who collect respiratory samples.

Déjà Vu: Coronaviruses and Transmission in Health Care Settings

Klompas and colleagues report an investigation of a SARS-CoV-2 cluster in an acute care hospital with transmission between patients and staff. The editorialists remind us of the need to reinforce and reeducate to improve practice of and adherence to important strategies that protect the entire health care ecosystem.

Co-Created Messaging for Influenza Vaccination in a High-Risk Hispanic Community Provides Groundwork for COVID-19 Vaccine

Purpose: Influenza/pneumonia is the eighth leading cause of death in the United States. The 2020-2021 influenza season is predicted to be further impacted by COVID-19 infections. Historical data reflect disproportionate morbidity and mortality rates in the Hispanic population for influenza and COVID-19. Influenza vaccination rates remain low in the Hispanic community. We aim to improve vaccination through a community-led event, partnering with the Cristo Rey School Dallas, located in a zip code with a higher age-adjusted influenza/pneumonia mortality rate. A survey was administered to adults attending the Influenza vaccine event to understand attitudes and perceptions about influenza, vaccination, and effective messaging strategies for the campaign. Methods: Messaging was cocreated with student health ambassadors to promote immunization and delivered through trusted sources. The health department administered vaccines to individuals >age 3 at no cost. Adults were asked to complete a 19-question survey postvaccination offered in both English and Spanish. Results: Two hundred and forty-one of 394 (61.2%) participants completed the survey. Ninety-eight percent identified as Hispanic/Latino, and the majority of surveys were administered in Spanish. Among Spanish language participants, the church bulletins (57.3%) and Spanish language radio (30.5%) were reported to be most effective modes of messaging versus word of mouth (32.9%) and social media (26.3%) for English-speaking participants. Sixteen percent of participants surveyed had never received an influenza vaccine before this event. Conclusion: Cocreated messaging delivered by trusted sources in the Hispanic community led to a successful Influenza vaccine drive with the Dallas County health department.

A Silver Lining? Fewer non-SARS-CoV-2 Respiratory Viruses during the COVID-19 Pandemic

Non-pharmaceutical interventions (NPIs) have “flattened the curve” of the COVID-19 pandemic, however the effect of these interventions on other respiratory viruses is unknown. We used aggregate level case count data for eight respiratory viruses and compared the institutional and statewide case counts before and during the period that NPIs were active. We observed a 61% (IRR 0.39, 95% CI 0.37 to 0.41, P < 0.0001) decrease in non-SARS-CoV-2 respiratory viral infections when NPIs were implemented. This finding, if further verified, should guide future public health initiatives to mitigate viral epidemics.

What the Coronavirus Disease 2019 (COVID-19) Pandemic Has Reinforced: The Need for Accurate Data

The COVID-19 pandemic has challenged the United States’ existing national public health informatics infrastructure. This report details the factors that have contributed to COVID-19 data inaccuracies and reporting delays and their effect on the modeling and monitoring of the COVID-19 pandemic.

Risk Factors for Healthcare Personnel Infection with Endemic Coronaviruses (HKU1, OC43, NL63, 229E): Results from the Respiratory Protection Effectiveness Clinical Trial (ResPECT)

Background

SARS-CoV-2 presents a large risk to healthcare personnel. Quantifying the risk of coronavirus infection associated with workplace activities is an urgent need.

Methods

We assessed the association of worker characteristics, occupational roles and behaviors, and participation in procedures with the risk of endemic coronavirus infection among healthcare personnel who participated in the Respiratory Protection Effectiveness Trial (ResPECT), a cluster randomized trial to assess personal protective equipment to prevent respiratory infections and illness conducted from 2011 to 2016.

Results

Among 4,689 HCP-seasons, we detected coronavirus infection in 387 (8%). HCP who participated in an aerosol generation procedure (AGP) at least once during the viral respiratory season were 105% (95% CI 21%, 240%) more likely to be diagnosed with a laboratory-confirmed coronavirus infection. Younger individuals, those who saw pediatric patients and those with household members under the age of five were at increased risk of coronavirus infection.

Conclusions

Our analysis suggests the risk of HCP becoming infected with an endemic coronavirus increases approximately two-fold with exposures to AGP. Our findings may be relevant to the Coronavirus Disease 2019 (COVID-19) pandemic; however, SARS-COV-2, the virus that causes COVID-19, may differ from endemic coronaviruses in important ways.

An "Infodemic": Leveraging High-Volume Twitter Data to Understand Early Public Sentiment for the Coronavirus Disease 2019 Outbreak

BACKGROUND

Twitter has been used to track trends and disseminate health information during viral epidemics. On January 21, 2020, the Centers for Disease Control and Prevention activated its Emergency Operations Center and the World Health Organization released its first situation report about coronavirus disease 2019 (COVID-19), sparking significant media attention. How Twitter content and sentiment evolved in the early stages of the COVID-19 pandemic has not been described.

METHODS

We extracted tweets matching hashtags related to COVID-19 from January 14 to 28, 2020 using Twitter's application programming interface. We measured themes and frequency of keywords related to infection prevention practices. We performed a sentiment analysis to identify the sentiment polarity and predominant emotions in tweets and conducted topic modeling to identify and explore discussion topics over time. We compared sentiment, emotion, and topics among the most popular tweets, defined by the number of retweets.

RESULTS

We evaluated 126 049 tweets from 53 196 unique users. The hourly number of COVID-19-related tweets starkly increased from January 21, 2020 onward. Approximately half (49.5%) of all tweets expressed fear and approximately 30% expressed surprise. In the full cohort, the economic and political impact of COVID-19 was the most commonly discussed topic. When focusing on the most retweeted tweets, the incidence of fear decreased and topics focused on quarantine efforts, the outbreak and its transmission, as well as prevention.

CONCLUSIONS

Twitter is a rich medium that can be leveraged to understand public sentiment in real-time and potentially target individualized public health messages based on user interest and emotion.

An "Infodemic": Leveraging High-Volume Twitter Data to Understand Early Public Sentiment for the Coronavirus Disease 2019 Outbreak

Background

Twitter has been used to track trends and disseminate health information during viral epidemics. On January 21, 2020, the Centers for Disease Control and Prevention activated its Emergency Operations Center and the World Health Organization released its first situation report about coronavirus disease 2019 (COVID-19), sparking significant media attention. How Twitter content and sentiment evolved in the early stages of the COVID-19 pandemic has not been described.

Methods

We extracted tweets matching hashtags related to COVID-19 from January 14 to 28, 2020 using Twitter’s application programming interface. We measured themes and frequency of keywords related to infection prevention practices. We performed a sentiment analysis to identify the sentiment polarity and predominant emotions in tweets and conducted topic modeling to identify and explore discussion topics over time. We compared sentiment, emotion, and topics among the most popular tweets, defined by the number of retweets.

Results

We evaluated 126 049 tweets from 53 196 unique users. The hourly number of COVID-19-related tweets starkly increased from January 21, 2020 onward. Approximately half (49.5%) of all tweets expressed fear and approximately 30% expressed surprise. In the full cohort, the economic and political impact of COVID-19 was the most commonly discussed topic. When focusing on the most retweeted tweets, the incidence of fear decreased and topics focused on quarantine efforts, the outbreak and its transmission, as well as prevention.

Conclusions

Twitter is a rich medium that can be leveraged to understand public sentiment in real-time and potentially target individualized public health messages based on user interest and emotion.

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.

Managing Emerging Infectious Diseases: Should Travel Be the Fifth Vital Sign?

In the setting of emerging infections, such as COVID-19, this commentary argues that all members of the health care team need training on how to integrate key epidemiologic information, such as travel history, into their risk assessments in the same way they are trained to ask about tobacco exposure to assess cancer and heart disease risk.

1204. Increased Risk of Respiratory Infections Among Healthcare Personnel (HCP) Caring for Children

Background

Healthcare personnel (HCP) are exposed to many individuals with respiratory illness while providing care. Because children more frequently present for care with respiratory infections compared with older individuals, we hypothesized that HCP working in pediatric settings might experience greater risks of respiratory infection than HCP working in adult settings. The Respiratory Protection Effectiveness Clinical Trial (ResPECT) prospectively compared respiratory protection among HCP at seven health systems across the United States between 2011 and 2015.

Methods

Swabs were collected from asymptomatic participants twice each respiratory season. Swabs were collected from symptomatic HCP within 24 hours of self-reported respiratory symptoms and again if participants were still symptomatic after 7 days. PCR confirmation for 13 viruses was done by a single laboratory. We compared hazards of multiple outcomes associated with respiratory infections among HCP working in pediatric clinics and HCP working in clinics that care for adults.

Results

The main outcomes were risk factors for symptomatic and asymptomatic viral respiratory infections. A total of 5,180 participant-seasons were evaluated from 2011–2015, 1,130 of which worked solely with children. There were 403 and 1,162 incidents of asymptomatic and symptomatic PCR-confirmed respiratory infection, respectively. Risk factors associated with respiratory infection in the entire cohort included age, race, vaccination status, smoking status, wearing contacts, total household members, study site, and age of patient population. HCP working exclusively with pediatric patients had 1.5 (95% CI 1.2–1.8) times the rate of respiratory virus infection compared with HCP working only with adults. HCP who worked with both populations had 1.4 times (95% CI: 1.2–1.7) the rate of infection with respiratory viruses.

Conclusion

The risk of respiratory infections was increased among HCP that saw children. This risk was not mitigated by working only part-time with children and extended to those who identified as working with both adult and pediatric populations. Our findings highlight the need to target interventions in pediatric settings to decrease HCP acquisition of respiratory infections.

Disclosures

Trish M. Perl, MD; MSc, 7–11: Advisory Board; medimmune: Research Grant.

547. Multidrug-Resistant Pseudomonas aeruginosa in an Academic Regional Burn Intensive Care Unit

Background

Pseudomonas aeruginosa infection can lead to morbidity, mortality and increased hospital length of stay especially in Burn Intensive Care Units (BICU) patients. Reports of multi-drug-resistant Pseudomonas aeruginosa outbreaks in the BICU are increasing. We investigated the epidemiology of Carbapenem-Resistant Pseudomonas aeruginosa (CRPA) in our BICU.

Methods

Clinical and laboratory characteristics of all CRPA isolates identified between 5/8/16 and 3/14/19, in an 11-bed BICU in an academic 870-bed public safety-net hospital were reviewed and defined as Meropenem MIC 4 or greater. Retained isolates were sent for pulse-field gel electrophoresis (PFGE). Infection prevention (IP) observations and interventions were intensified and environmental cultures were collected. Patient charts were reviewed.

Results

27 patients between ages 5–61 years old were found to have CRPA (only 2 patients < 18 years). 21/27 (77.7%) were male. 21/27 (77.7%) had >40% total body surface area (TBSA) burns, 3/27 (11.1%) had 20–39% TBSA burn and 1/27 (3.7%) had < 20% TBSA burn. 19/27 (70.3%) patients had bacteremia, 6 had respiratory infections with 3 (11.1%) Infection-related Ventilator-Associated Complications (IVAC), 3 had urinary tract infection, and 1 had CRPA from a central venous catheter tip. There were very few co-morbidities. Twenty isolates from 11 different patients were typed and revealed 2 different clonal strains. 5/11 (45%) patients had strain A, and 2/11 (18%) patients had strain B. 3/11 (27.2%) patients had unique strains. CRPA was isolated from 5 different rooms. Water cultures did not reveal CRPA. Failure of hand hygiene, non-adherence to isolation/PPE protocols and clutter were found. Each failure was corrected. No new CRPA patient isolates have been identified.

Conclusion

Transmission was halted by reinforcement of IP measures. Importantly water was not a source of CRPA in this setting and the data suggest transmission due to environmental contamination.

Disclosures

Trish M. Perl, MD; MSc, 7–11: Advisory Board; medimmune: Research Grant

1205. Healthcare Personnel Knowledge, Attitudes, and Beliefs Towards Infection Prevention and Control Measures for Protection from Respiratory Infections

Background

Healthcare personnel (HCP) knowledge and attitudes toward Infection Prevention and Control (IPC) measures are important determinants of practices that can protect them from acquisition of infectious diseases from patients. We aimed to describe HCP knowledge and attitudes concerning IPC measures over time in the context of a clinical trial.

Methods

ResPECT was a multi-center, multi-season cluster randomized clinical trial designed to compare the effectiveness of medical masks (MM) and N95 respirators (N95) for preventing acute respiratory illnesses in HCP employed in outpatient clinical settings. At the beginning of each respiratory virus season, participants completed a survey instrument to measure IPC knowledge. At the beginning and end of each season participants completed a survey to assess attitudes and beliefs about IPC measures, especially MM and N95.

Results

A pre-study and post-study survey pair was available for 88.1% of participant seasons. There were no significant differences in demographic variables or job assignment between survey respondents and nonrespondents for each participant season. Participants correctly identified 59.8% to 63.4% of IPC measures that should be used by HCP when exposed to patients with symptoms of acute respiratory illness, or at high risk of infection. There was modest improvement in the knowledge score over time among providers who participated for multiple years in the study. In the first pre-study survey of IPC attitudes and beliefs, 88.5% and 87.9% of participants identified at least one reason to avoid using either MM and N95, respectively (Figure 1). At the post-season survey, the proportion of participants reporting a reason to avoid MM fell to 39.6% (IRR for pre- vs. post-season 0.15, 95% CI 0.13–0.17) and 53.6% reported a reason to avoid N95 (IRR 0.57, 95% CI 0.51–0.66).

Conclusion

HCPknowledge of IPC precautions was poor, suggesting a need for better IPC education and accountability in the outpatient setting. When given incentives to comply with processes toward which they had negative attitudes at baseline, HCP realized that medical masks and N95 respirators were comfortable enough to wear for patient encounters and interfered with their work processes less than expected.

Disclosures

Trish M. Perl, MD; MSc, 7–11: Advisory Board; medimmune: Research Grant.

N95 Respirators vs Medical Masks for Preventing Influenza Among Health Care Personnel: A Randomized Clinical Trial

Importance

Clinical studies have been inconclusive about the effectiveness of N95 respirators and medical masks in preventing health care personnel (HCP) from acquiring workplace viral respiratory infections.

Objective

To compare the effect of N95 respirators vs medical masks for prevention of influenza and other viral respiratory infections among HCP.

Design, Setting, and Participants

A cluster randomized pragmatic effectiveness study conducted at 137 outpatient study sites at 7 US medical centers between September 2011 and May 2015, with final follow-up in June 2016. Each year for 4 years, during the 12-week period of peak viral respiratory illness, pairs of outpatient sites (clusters) within each center were matched and randomly assigned to the N95 respirator or medical mask groups.

Interventions

Overall, 1993 participants in 189 clusters were randomly assigned to wear N95 respirators (2512 HCP-seasons of observation) and 2058 in 191 clusters were randomly assigned to wear medical masks (2668 HCP-seasons) when near patients with respiratory illness.

Main Outcomes and Measures

The primary outcome was the incidence of laboratory-confirmed influenza. Secondary outcomes included incidence of acute respiratory illness, laboratory-detected respiratory infections, laboratory-confirmed respiratory illness, and influenzalike illness. Adherence to interventions was assessed.

Results

Among 2862 randomized participants (mean [SD] age, 43 [11.5] years; 2369 [82.8%]) women), 2371 completed the study and accounted for 5180 HCP-seasons. There were 207 laboratory-confirmed influenza infection events (8.2% of HCP-seasons) in the N95 respirator group and 193 (7.2% of HCP-seasons) in the medical mask group (difference, 1.0%, [95% CI, -0.5% to 2.5%]; P = .18) (adjusted odds ratio [OR], 1.18 [95% CI, 0.95-1.45]). There were 1556 acute respiratory illness events in the respirator group vs 1711 in the mask group (difference, -21.9 per 1000 HCP-seasons [95% CI, -48.2 to 4.4]; P = .10); 679 laboratory-detected respiratory infections in the respirator group vs 745 in the mask group (difference, -8.9 per 1000 HCP-seasons, [95% CI, -33.3 to 15.4]; P = .47); 371 laboratory-confirmed respiratory illness events in the respirator group vs 417 in the mask group (difference, -8.6 per 1000 HCP-seasons [95% CI, -28.2 to 10.9]; P = .39); and 128 influenzalike illness events in the respirator group vs 166 in the mask group (difference, -11.3 per 1000 HCP-seasons [95% CI, -23.8 to 1.3]; P = .08). In the respirator group, 89.4% of participants reported "always" or "sometimes" wearing their assigned devices vs 90.2% in the mask group.

Conclusions and Relevance

Among outpatient health care personnel, N95 respirators vs medical masks as worn by participants in this trial resulted in no significant difference in the incidence of laboratory-confirmed influenza.

Trial Registration

ClinicalTrials.gov Identifier: NCT01249625.

Does Use of Electronic Alerts for Systemic Inflammatory Response Syndrome (SIRS) to Identify Patients With Sepsis Improve Mortality?

PURPOSE

The objective of this study was to assess whether earlier antibiotic administration in patients with systemic inflammatory response syndrome (SIRS) and evidence of organ dysfunction identified through electronic alerts improves patient mortality.

METHODS

This is a retrospective observational cohort study of adult patients admitted across 5 acute-care hospitals. Mortality, Premier CareScience^TM Analytics Expected Mortality Score, and clinical and demographic variables were obtained through the electronic medical record and Premier (Premier Healthcare Solutions, Inc, Charlotte NC) reports. Patients with 2 SIRS criteria and organ dysfunction were identified through an automated alert. Univariate and multivariate logistic regression was performed.

RESULTS

Of those with SIRS and organ dysfunction, 8146 patients were identified through the electronic Best Practice Alert (BPA). Overall 30-day mortality rate was 8.7%. There was no significant association between time to antibiotic administration from BPA alert and mortality (P = 0.21) after adjusting for factors that could influence mortality, including age, heart rate, blood pressure, plasma lactate levels, creatinine, bilirubin levels, and the CareScience^TM Predicted Mortality Risk Score. Female gender (odds ratio [OR] 1.31, 95% confidence interval [CI] 1.06-1.63) and facility were also independently associated with mortality.

CONCLUSION

The use of alerts in the electronic medical record may misclassify patients with SIRS as having sepsis. Time to antibiotic administration in patients meeting SIRS criteria and evidence of end-organ dysfunction through BPA alerts did not affect 30-day mortality rates across a health system. Patient severity of illness, gender, and facility also independently predicted mortality. There were higher rates of antibiotic use and Clostridioides difficile infection in patients with BPA alerts.

National Costs Associated With Methicillin-Susceptible and Methicillin-Resistant Staphylococcus aureus Hospitalizations in the United States, 2010-2014

Background

Infections caused by methicillin-resistant Staphylococcus aureus (MRSA) have been associated with worse patient outcomes and higher costs of care than methicillin-susceptible (MSSA) infections. However, since prior studies found these differences, the healthcare landscape has changed, including widespread dissemination of community-associated strains of MRSA. We sought to provide updated estimates of the excess costs of MRSA infections.

Methods

We conducted a retrospective analysis using data from the National Inpatient Sample from the Agency for Healthcare Research and Quality for the years 2010-2014. We calculated costs for hospitalizations, including MRSA- and MSSA-related septicemia and pneumonia infections, as well as MRSA- and MSSA-related infections from conditions classified elsewhere and of an unspecified site ("other infections"). Differences in the costs of hospitalization were estimated using propensity score-adjusted mortality outcomes for 2010-2014.

Results

In 2014, estimated costs were highest for pneumonia and sepsis-related hospitalizations. Propensity score-adjusted costs were significantly higher for MSSA-related pneumonia ($40725 vs $38561; P = .045) and other hospitalizations ($15578 vs $14792; P < .001) than for MRSA-related hospitalizations. Similar patterns were observed from 2010 to 2013, although crude cost differences between MSSA- and MRSA-related pneumonia hospitalizations rose from 25.8% in 2010 to 31.0% in 2014. Compared with MSSA-related hospitalizations, MRSA-related hospitalizations had a higher adjusted mortality rate.

Conclusions

Although MRSA infections had been previously associated with higher hospitalization costs, our results suggest that, in recent years, costs associated with MSSA-related infections have converged with and may surpass costs of similar MRSA-related hospitalizations.

Face Mask Use and Persistence of Livestock-associated Staphylococcus aureus Nasal Carriage among Industrial Hog Operation Workers and Household Contacts, USA

BACKGROUND

Industrial hog operation (IHO) workers may persistently carry antibiotic-resistant, livestock-associated Staphylococcus aureus in their nasal cavities. It is unclear whether IHO work activities can alter IHO workers' and their household members' exposure to these bacteria.

OBJECTIVE

Our objective was to investigate the relationship of IHO work activities with persistence of antibiotic-resistant, livestock-associated S. aureus nasal carriage among IHO workers and their household members.

METHODS

At biweekly intervals over 4 months, IHO workers and their household members completed questionnaires and provided nasal swabs that were assessed for S. aureus, multidrug-resistant S. aureus (MDRSA), and livestock-associated markers (tetracycline resistance, scn absence, spa type). We examined the association between transient and habitual IHO work activities and S. aureus nasal carriage outcomes.

RESULTS

One hundred one IHO workers and 79 household members completed 1,456 study visits. Face mask use (each 25% increase) was associated with reduced odds of nasal carriage of MDRSA (odds ratio [OR]: 0.65 [95% confidence interval (CI): 0.46, 0.92], tetracycline-resistant S. aureus [OR = 0.74 (95% CI: 0.56, 0.97)], and S. aureus clonal complex (CC) 398/CC9 [OR = 0.77 (95% CI: 0.60, 0.99)]. IHO workers who ever (vs. never) gave pigs injections had higher odds of these outcomes. Among household members, living with an IHO worker who consistently ([Formula: see text] of the time) versus sometimes or never used a face mask was associated with reduced odds of carrying scn-negative S. aureus, tetracycline-resistant S. aureus, and S. aureus CC398/CC9 (OR range: 0.12-0.20, all [Formula: see text]), and consistent IHO worker coveralls use was associated with reduced odds of household member MDRSA carriage only. Living with an IHO worker who habitually had contact with [Formula: see text] hogs (vs. [Formula: see text]) was associated with higher odds of household member livestock-associated S. aureus carriage.

CONCLUSIONS

Consistent face mask use was associated with reduced exposure to antibiotic-resistant, livestock-associated S. aureus among IHO workers and their household members. https://doi.org/10.1289/EHP3453.

Outpatient Parenteral Therapy for Complicated Staphylococcus aureus Infections: A Snapshot of Processes and Outcomes in the Real World

Background

In the United States, patients discharged on outpatient parenteral antimicrobial therapy (OPAT) are often treated by home health companies (HHCs) or skilled nursing facilities (SNFs). Little is known about differences in processes and outcomes between these sites of care.

Methods

We performed a retrospective study of 107 patients with complicated Staphylococcus aureus infections discharged on OPAT from 2 academic medical centers. Clinical characteristics, site of posthospital care, process measures (lab test monitoring, clinic follow-up), adverse events (adverse drug events, Clostridium difficile infection, line events), and clinical outcomes at 90 days (cure, relapse, hospital readmission) were collected. Comparisons between HHCs and SNFs were conducted.

Results

Overall, 33% of patients experienced an adverse event during OPAT, and 64% were readmitted at 90 days. Labs were received for 44% of patients in SNFs and 56% of patients in HHCs. At 90 days after discharge, a higher proportion of patients discharged to an SNF were lost to follow-up (17% vs 3%; P = .03) and had line-related adverse events (18% vs 2%; P < .01). Patients discharged to both sites of care experienced similar clinical outcomes, with favorable outcomes occurring in 61% of SNF patients and 70% of HHC patients at 90 days. There were no differences in rates of relapse, readmission, or mortality.

Conclusions

Patients discharged to SNFs may be at higher risk for line events than patients discharged to HHCs. Efforts should be made to strengthen basic OPAT processes, such as lab monitoring and clinic follow-up, at both sites of care.

A polymicrobial fungal outbreak in a regional burn center after Hurricane Sandy

OBJECTIVE

To describe a polymicrobial fungal outbreak after Hurricane Sandy.

DESIGN

An observational concurrent outbreak investigation and retrospective descriptive review.

SETTING

A regional burn intensive care unit that serves the greater Baltimore area, admitting 350-450 burn patients annually.

PATIENTS

Patients with burn injuries and significant dermatologic diseases such as toxic epidermal necrolysis who were admitted to the burn intensive care unit.

METHODS

An outbreak investigation and a retrospective review of all patients with non-candida fungal isolates from 2009-2016 were performed.

RESULTS

A polymicrobial fungal outbreak in burn patients was temporally associated with Hurricane Sandy and associated with air and water permeations in the hospital facility. The outbreak abated after changes to facility design.

CONCLUSIONS

Our results suggest a possible association between severe weather events like hurricanes and nosocomial fungal outbreaks. This report adds to the emerging literature on the effect of severe weather on healthcare-associated infections.

Healthcare personnel exposure in an emergency department during influenza season

Introduction

Healthcare personnel are at high risk for exposure to influenza by direct and indirect contact, droplets and aerosols, and by aerosol generating procedures. Information on air and surface influenza contamination is needed to assist in developing guidance for proper prevention and control strategies. To understand the vulnerabilities of healthcare personnel, we measured influenza in the breathing zone of healthcare personnel, in air and on surfaces within a healthcare setting, and on filtering facepiece respirators worn by healthcare personnel when conducting patient care.

Methods

Thirty participants were recruited from an adult emergency department during the 2015 influenza season. Participants wore personal bioaerosol samplers for six hours of their work shift, submitted used filtering facepiece respirators and medical masks and completed questionnaires to assess frequency and types of interactions with potentially infected patients. Room air samples were collected using bioaerosol samplers, and surface swabs were collected from high-contact surfaces within the adult emergency department. Personal and room bioaerosol samples, surface swabs, and filtering facepiece respirators were analyzed for influenza A by polymerase chain reaction.

Results

Influenza was identified in 42% (53/125) of personal bioaerosol samples, 43% (28/ 96) of room bioaerosol samples, 76% (23/30) of pooled surface samples, and 25% (3/12) of the filtering facepiece respirators analyzed. Influenza copy numbers were greater in personal bioaerosol samples (17 to 631 copies) compared to room bioaerosol samples (16 to 323 copies). Regression analysis suggested that the amount of influenza in personal samples was approximately 2.3 times the amount in room samples (Wald χ2 = 16.21, p<0.001).

Conclusions

Healthcare personnel may encounter increased concentrations of influenza virus when in close proximity to patients. Occupations that require contact with patients are at an increased risk for influenza exposure, which may occur throughout the influenza season. Filtering facepiece respirators may become contaminated with influenza when used during patient care.

Gonococcal Conjunctivitis: A Case Report of an Unusual Mode of Transmission

BACKGROUND

Outside of the newborn period, development of gonococcal conjunctivitis is rare and predominantly occurs through autoinoculation. We report an unusual case of gonococcal conjunctivitis in a young woman exposed through direct inoculation.

CASE

A 19-year-old woman presented with purulent ocular discharge, severe pain, and decreased vision unresponsive to topical antibiotics or ganciclovir approximately 3 weeks after accidental ocular exposure to seminal fluid during unprotected oral sex. Cultured ocular drainage grew Neisseria gonorrhea; vaginal and throat cultures were negative. She was successfully treated with ceftriaxone and doxycycline for 10 days.

SUMMARY AND CONCLUSION

Clinicians should be aware of the potential for vision-threatening gonococcal conjunctivitis from exposure during sexual contact.

Assessment of operating room airflow using air particle counts and direct observation of door openings

BACKGROUND

The role of the operating room (OR) environment has been thought to contribute to surgical site infection rates. The quality of OR air, disruption of airflow, and other factors may increase contamination risks. We measured air particulate counts (APCs) to determine if they increased in relation to traffic, door opening, and other common activities.

METHODS

During 1 week, we recorded APCs in 5-minute intervals and movement of health care workers. Trained observers recorded information about traffic, door openings, job title of the opener, and the reason for opening.

RESULTS

At least 1 OR door was open during 47% of all readings. There were 13.4 door openings per hour during cases. Door opening rates ranged from 0.19-0.28 per minute. During this time, a total of 660 air measurements were obtained. The mean APCs were 9,238 particles (95% confidence interval [CI], 5,494- 12,982) at baseline and 14,292 particles (95% CI, 12,382-16,201) during surgery. Overall APCs increased 13% when either door was opened (P < .15). Larger particles that correlated to bacterial size were elevated significantly (P < .001) on door opening.

CONCLUSIONS

We observed numerous instances of verbal communication and equipment movement. Improving efficiency of communication and equipment can aid in reduction of traffic. Further study is needed to examine links between microbiologic sampling, outcome data, and particulate matter to enable study of risk factors and effects of personnel movement.

Minimizing hair dispersal: Is this an opportunity for improvement in health care-acquired infection prevention?

We performed a study to understand common practices in surgical site hair removal and barriers to guideline compliance in surgical site hair removal. We found most health care providers in the United States do not remove hair outside of the operating room. Our findings reveal minimizing hair dispersal in the operating room, including improved and innovative ways for collecting clipped loose hair, is a significant area for improvement in surgical quality and health care-acquired infection prevention.