Infection Control and Hospital Epidemiology最新文献

We describe an outbreak of hospital-acquired Legionella pneumonia in a hematology ward; a cold drinking water dispenser was identified as the source. Regular surveillance and provision of appropriate water quality to high-risk patients are critical, and hospitals should be aware of the risks associated with the use of these devices.

Background: Algorithms using electronic health record data to identify children with community-acquired pneumonia (CAP) and to evaluate the appropriateness of antibiotic use may facilitate antibiotic stewardship efforts, but validated measures of antibiotic choice and duration are unavailable.

Methods: We performed a cross-sectional study within a single hospital system, including hospitalized children ages 6 months to 17 years who were admitted between 1/1/2019 and 10/31/2022. CAP was defined electronically as an ICD-10 code for pneumonia, a chest x-ray or chest CT within 48 hours of admission, and at least two days of antibiotics starting within 48 hours of admission. Hospital transfers and those who died within 48 hours or had chronic conditions, intensive care unit stays ≥48 hours, or concurrent infections were excluded. We validated electronic measures of appropriate antibiotic choice and duration using a reference standard of manual chart review. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for each metric.

Results: The electronic algorithm identified 1058 CAP encounters, and 100 were randomly selected for validation. Inappropriate antibiotic choice and duration occurred in one and 75 encounters of the 100 encounters, respectively, based on manual chart review. The electronic algorithm had a sensitivity of 100%, specificity of 93%, PPV of 14%, and NPV of 100% for inappropriate antibiotic choice and a sensitivity of 97%, specificity of 88%, PPV of 96%, and NPV of 92% for inappropriate antibiotic duration.

Conclusion: Metrics of inappropriate antibiotic choice and duration had acceptable performance characteristics and may facilitate syndrome-based stewardship efforts.

This multisociety guidance was endorsed by SHEA, APIC, IDSA, PALTmed, and AGS. It provides recommendations for infection prevention and control (IPC) in the context of the increasing complexity of nursing home care in the United States: increased medical acuity of residents, the spread of multidrug-resistant organisms, and the threat of emerging pathogens. Recommendations and implementation suggestions address IPC leadership, staffing, and resources, healthcare personnel and residents' adherence to precautions and effective hand hygiene, outbreak preparedness, training, occupational health, cleaning and disinfection in the care environment, and the involvement of IPC in the facility. The guidance also addresses the challenges of maintaining a home-like care space while sustaining necessary IPC measures. The guidance covers the role of regulatory bodies like the Centers for Medicare and Medicaid Services (CMS) and recommendations from the Centers for Disease Control and Prevention (CDC). It should serve as a resource for IPC program leaders in nursing homes who are aiming to enhance infection prevention efforts.

Molecular tests without well-defined test performance characteristics are increasingly available for diagnosis of infectious diseases. These tests present a diagnostic stewardship challenge for institutions. We share the results of a local modified Delphi consensus undertaken to define appropriate scenarios for use of plasma metagenomic next-generation sequencing.

Objective: Inappropriate urine cultures (UCs) are common and lead to inappropriate antimicrobial use. Urinalyses (UAs) have been increasingly incorporated into diagnostic stewardship interventions, but the impact of these interventions nationally has not been assessed. We describe UA and UC utilization practices using a nationwide dataset of patients admitted to acute care hospitals.

Methods: Design, Setting and Participants: We performed a retrospective cohort study of index UCs and their associated UAs performed for adult patients (age ≥ 18 years) admitted in U.S. acute care hospitals, participating in the PINC AI™ Healthcare Database (PHD) from January 1, 2017, through December 31, 2020. A positive UA was defined as >10 leukocytes per high power field, positive leukocyte esterase, or positive nitrite.

Results: The overall rate of UCs in this study was 124.7 per 1000 discharges and annual UC rates decreased from 2017 (129.2) to 2020 (120.0). The proportion of UCs that had a positive UA increased from 60.5% in 2017 to 68.1% in 2020; UCs without a UA decreased from 19.3% to 10.5%, and UCs with a negative UA did not significantly change (20.2% to 21.5%). A multivariate multinomial logistic regression model identified male sex, age <65, and a diagnosis of cancer to be predictors of having a UC with a negative UA or no UA.

Conclusions: UC utilization decreased over the study period. The proportion of UCs with a positive UA increased. This may suggest a positive impact of diagnostic stewardship practices at the national level although further progress is needed.

Following recognition that our hospital had higher use of plasma metagenomic next-generation sequencing than our peers, we implemented a process for approval by infectious diseases before test collection. This intervention is calculated to result in a direct cost savings of $79,505-$84,057/year, driven mainly by reduced laboratory costs.

Objective: Evaluate the prevalence and risk factors for inappropriately ordered urine cultures in primary care.

Design: Cross-sectional study using chart reviews.

Setting: Two primary care, safety-net clinics in Houston, Texas.

Patients: Non-pregnant adults without a urinary catheter who had a urine culture and a primary care visit between 11/2018 and 3/2020.

Methods: We classified patients lacking physician documentation of the following symptoms as having an inappropriately ordered urine culture: dysuria, frequency, urgency, hematuria, fever, chills, costovertebral angle tenderness, nephrolithiasis, and pain (suprapubic, pelvic, or flank). We extracted patient demographics, visit-related diagnostic codes, past medical history, and urine culture results. Diagnostic codes were grouped based on body system, visit type (e.g. routine visit), or sign or symptom clusters. We evaluated the relationship between these factors and inappropriately ordered cultures using generalized estimating equations logistic regression.

Results: We included 807 patients who had 870 visits. Most patients were Hispanic (66.3%) or African American/Black (24.8%) females (76.1%) with a median age of 50 years. Among 870 cultures, 210 (24%) were ordered inappropriately. We found having an abnormal urinalysis or urine characteristic (adjusted odds ratio (aOR): 13.66), acute low back pain (aOR: 4.88), a cardiovascular-related (aOR: 1.68) or gynecological/family planning visit (aOR: 10.84), being evaluated at the non-teaching clinic (aOR: 6.03), or having a routine health visit (aOR: 1.81) within the non-teaching clinic (interaction aOR: 4.27) were significantly associated with inappropriate urine cultures.

Conclusions: Our study revealed factors associated with inappropriately ordered urine cultures that may be unique to ambulatory settings and can help design outpatient diagnostic stewardship interventions.

Clostridioides difficile infection (CDI) guidelines advise against repeat testing within 7 days. This retrospective study identified factors associated with 7-day repeat testing. Attending physicians (aOR = 0.67) and advanced practice practitioners (aOR = 0.61) ordered fewer repeat tests compared to residents. Further research is necessary to address inappropriate repeat testing.

Objective: We aimed to decrease the difference in first-line therapy (ΔFLT) for common acute respiratory infections (ARI) in pediatric urgent care clinics (PUCs) in relation to race, ethnicity, language, and insurance using quality improvement (QI) methodology.

Design: Retrospective cohort study of 13-month pre-intervention (April 2022-April 2023) and 17-month (May 2023-September 2024) intervention data collection.

Setting: 92 PUC sites from 9 organizations spanning 22 states.

Patients: Encounters of patients 6 months to 18 years of age with ARI diagnoses.

Methods: Sites created local multidisciplinary QI teams, cause-and-effect analyses, driver diagrams, and used Plan-Do-Study-Act (PDSA) cycles. We defined FLT per national guidelines. We measured ΔFLT between socioeconomic groups as our primary outcome. Balancing measure was overall rate of FLT. Logistic regression models evaluated the impact education-only PDSAs had on ΔFLT compared to PDSAs that used education plus another intervention modality (eg clinical decision support).

Results: We included 895,604 encounters. Despite our QI efforts, we saw no change in ΔFLT between Spanish and English-speaking patients (3.1%), Hispanic and non-Hispanic patients (1.6%), or commercial and government-insured patients (1.6%). We saw an increase in ΔFLT between Black and White patients from 3.6% to 5.8%. We observed fluctuations in overall rates of FLT over time. The impact of PDSA cycle types was variable.

Conclusions: Despite local interventions to reduce differences in prescribing, we noted a widening of the ΔFLT by race. More work is needed to understand causes of these disparities and develop effective interventions that improve equitable antibiotic prescribing.