Infection Control and Hospital Epidemiology最新文献

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.

Objective: Microbial contamination of textiles in healthcare settings is common and hypothesized to contribute to pathogen transfer. This systematic literature review aims to summarize the current evidence on microorganism transfer to and from textiles in healthcare and on factors that influence transfer.

Design: Systematic literature review.

Methods: Cochrane, Medline/Ovid, EMBASE, and Web of Science were searched. Studies were included if the transfer experiment involved textiles as origin material or destination material, the transfer mechanism was described accurately, and transfer events were quantifiable. Results on transfer and factors associated with transfer were extracted.

Results: We included 21 studies with 490 transfer experiments. Considerable heterogeneity in all relevant study variables resulted in a very broad range of reported transfer proportions, from less than 1% to up to 100%. Cotton was the most frequently studied textile (13 studies) while Staphylococcus aureus was the most frequent pathogen of interest (13 studies). Highest transfer proportions (85-100%) were reported in transfer experiments from solid surfaces to textiles by wiping. Very low transfer proportions (0.01-2.5%) were reported in transfer experiments from textiles to textiles by pressure. Moisture and friction were associated with higher transfer.

Conclusions: This study highlights the wide range of microbial transfer quantity from and to textiles in healthcare, depending on transfer mechanism, moisture, and other factors. The findings can inform the design of infection prevention and control (IPC) practices in healthcare.

Background: Platelet-rich plasma (PRP) injections are increasingly performed in outpatient settings to treat select musculoskeletal injuries, arthritis, hair loss, and wounds. There is a need for procedure-specific guidance and standardization of PRP practices to mitigate associated infection prevention (IP) risks such as bloodborne pathogen exposure and unsafe injection use.

Objective: Develop a standardized approach for PRP administration which incorporates existing IP regulatory and professional society guidance.

Methods: Observation and descriptive review of PRP injection protocols across subspecialties at a tertiary medical center, focused on ambulatory IP and regulatory standards compliance. Development of a standardized operating procedure (SOP) to mitigate IP risks and align with regulatory guidance.

Results: Observations were completed in orthopedic, wound care, and oral maxillofacial surgery clinics. Variability in practice was noted for product labeling, centrifugation, and injection modalities. A multidisciplinary workgroup convened to develop and operationalize an SOP. Classification of PRP as a blood product introduced nuances to protocols for product preparation, handling, administration, labeling, and documentation to comply with regulatory standards.

Conclusions: Development and implementation of an SOP for PRP treatment requires an awareness of the scope of practice in a healthcare system and identification of pertinent regulatory standards for integration into workflows. Partnerships between IP teams, subspecialty clinical providers, blood safety experts, quality and safety teams, and healthcare technology are essential to minimize variability in practice, ensure safety of patients and healthcare personnel, and align with regulatory standards.

Background: The clinical impact of carbapenem-resistant Acinetobacter baumannii (CRAB) remains controversial, with uncertainty about whether it directly contributes to mortality or merely reflects underlying patient's morbidity. This study aimed to evaluate the impact of CRAB colonization and infection on patient outcomes.

Methods: A retrospective cohort study was conducted in an Israeli tertiary hospital between January 2023 and December 2024. Patients were categorized into CRAB-negative (A group), CRAB-present on admission (POA, B group), and hospital-acquired CRAB (C group). Time-varying Cox proportional hazards models were used to estimate 30- and 90-day mortality risks while adjusting for immortal time bias. Kaplan-Meier and cumulative hazard curves were generated, and univariable Firth logistic regressions were performed as exploratory analyses.

Results: Of 3,080 patients, 149 had CRAB-POA and 108 acquired CRAB. Risk factors for CRAB-POA included long-term care facility residence (odds ratio (OR) = 4.1) and mechanical ventilation (OR = 2.3). Hospital-acquired CRAB was associated with longer length of stay and ventilation. Time-varying Cox models adjusting for immortal time bias showed that both CRAB colonization and infection were associated with increased 30-day mortality (hazard ratio (HR) range: 1.95-2.88) and 90-day mortality (HR range: 2.11-2.93), compared with CRAB-negative patients. Implementation of enhanced screening and cohorting in the late study period was associated with reduced CRAB acquisition (OR = 0.13, 95% confidence interval (CI): 0.07-0.24) and mortality (OR = 0.62, 95% CI: 0.41-0.94).

Conclusions: Both CRAB colonization and infection are associated with twofold increase in mortality after adjusting for disease severity. Enhanced infection control measures reduced acquisition and mortality.

Objective: We assessed the impact of an oral care initiative on non-ventilator-associated hospital-acquired pneumonia (NV-HAP) risk using two different measurement strategies.

Methods: We evaluated changes in NV-HAP events among all patients admitted to 17 VA Medical Centers (1) across the period 10/01/2015-12/31/2019, and (2) one-year pre- vs post- each hospital's oral care initiative start date. We modeled and compared observed versus predicted NV-HAP events per hospitalization using (1) an electronic clinical definition and (2) diagnosis codes, adjusting for patients' demographics, vital signs, and laboratory results at presentation.

Results: Among 333,257 hospitalizations, 1,922 (0.58%) met NV-HAP electronic clinical criteria and 2,386 (0.72%) diagnostic coding criteria. The risk of NV-HAP defined by electronic clinical criteria was 0.62% in October 2015 and 0.54% in December 2019 (estimated difference -0.084% [95% CI: -0.17%, 0.0056%]; the risk of NV-HAP defined by diagnostic coding decreased from 1.0% to 0.48% (estimated difference -0.53% [-0.63%, -0.43%]). In the one-year pre- vs post-analysis, there was no evidence of effect of the implementation on NV-HAP using either electronic clinical criteria (adjusted risk difference -0.078% (95% CI: -0.25%, 0.091%) or diagnostic coding criteria (adjusted risk difference -0.021% (95% CI: -0.18%, 0.14%).

Conclusions: In a large multi-center study of hospitalized patients, we were unable to identify a clear effect of an oral care initiative on NV-HAP using electronic clinical criteria or diagnostic coding criteria.

Objective: The study aimed to summarize estimates of key epidemiological parameters to improve the effectiveness of Clostridioides difficile infection (CDI) mathematical models and quantitatively characterize high-touch surfaces (HTSs) and mutual-touch surfaces in healthcare settings.

Methods: We systematically searched four databases and applied predefined eligibility criteria to screen, select, and include peer-reviewed studies in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The study is registered in the International Prospective Register of Systematic Reviews (CRD42023408483).

Results: Among the 21 C. difficile infection modeling studies, 76.2% used compartmental model approaches that group patients into infection disease categories such as susceptible, infected, or recovered, while 23.8% applied agent-based model approaches that simulate individual patients, staff, or surfaces. Key epidemiological parameters varied widely: estimates of how many new cases one patient could cause-the basic reproduction number (R₀)-ranged from 0.28, suggesting limited hospital spread, to as high as 2.6, which implies sustained in-hospital transmission. Incubation periods were reported between 4 and 18 days. Recovery and recurrence rates also differed across studies. Quantitative HTSs ranking revealed that bed rails, bedside tables, and supply carts were the top three most frequently touched surfaces.

Conclusions: Our findings highlight that modeling studies used different assumptions and estimates, creating variations in results. Clinicians should interpret modeling outputs, such as predicted spread or effectiveness of an intervention carefully, as differences may reflect real-world variation between hospitals or methodological variation. Developing infection models that reflect real-world conditions will enable healthcare teams better simulate and prioritize interventions, optimize cleaning protocols, and improve CDI transmission models for more targeted prevention.