Empiric broad-spectrum antibiotic therapy is commonly prescribed for patients hospitalized with diabetic foot infections (DFI) and lower extremity osteomyelitis (OM). The primary objective was to evaluate the concordance between empiric antibiotic therapy, microbiologic results, and definitive antibiotic therapy with a focus on methicillin-resistant Staphylococcus aureus (MRSA) and resistant gram-negative organisms. The secondary objective was to evaluate the negative predictive values (NPV) of select risk factors for MRSA and resistant gram-negative organisms for microbiologic results with these organisms.

Retrospective cohort study.

Safety-net health system in Ohio.

Adults hospitalized and receiving antibiotic therapy for DFI or lower extremity OM in 2021.

For 259 unique patients, empiric therapies with activity against MRSA and resistant gram-negative organisms were administered to 224 (86.5%) and 217 (83.8%) patients, respectively. Definitive therapies with activity against MRSA and resistant gram-negative organisms were administered to 91 (35%) and 74 (28.6%) patients, respectively. Of 234 patients with microbiologic testing, 29 (12.4%) had positive cultures with MRSA and 41 (17.5%) with resistant gram-negative organisms. The NPVs of risk factors for MRSA and resistant gram-negative organisms for the absence of these organisms in culture were 91% and 85%, respectively.

For patients hospitalized with DFI and lower extremity OM, our data suggest opportunities for substantial reductions in empiric therapies with activity against MRSA and resistant gram-negative organisms. The absence of risk factors for these organisms was reasonably good at predicting negative cultures with these organisms.

To identify characteristics associated with positive severe acute respiratory coronavirus virus 2 (SARS-CoV-2) polymerase chain reaction (PCR) tests in healthcare personnel.

Retrospective cohort study.

A multihospital healthcare system.

Employees who reported SARS-CoV-2 exposures and/or symptoms of coronavirus disease 2019 (COVID-19) between March 30, 2020, and September 20, 2020, and were subsequently referred for SARS-CoV-2 PCR testing.

Data from exposure and/or symptom reports were linked to the corresponding SARS-CoV-2 PCR test result. Employee demographic characteristics, occupational characteristics, SARS-CoV-2 exposure history, and symptoms were evaluated as potential risk factors for having a positive SARS-CoV-2 PCR test.

Among 6,289 employees who received SARS-CoV-2 PCR testing, 873 (14%) had a positive test. Independent risk factors for a positive PCR included: working in a patient care area (relative risk [RR], 1.82; 95% confidence interval [CI], 1.37–2.40), having a known SARS-CoV-2 exposure (RR, 1.20; 95% CI, 1.04–1.37), reporting a community versus an occupational exposure (RR, 1.87; 95% CI, 1.49–2.34), and having an infected household contact (RR, 2.47; 95% CI, 2.11–2.89). Nearly all HCP (99%) reported symptoms. Symptoms associated with a positive PCR in a multivariable analysis included loss of sense of smell (RR, 2.60; 95% CI, 2.09–3.24) or taste (RR, 1.75; 95% CI, 1.40–2.20), cough (RR, 1.95; 95% CI, 1.40–2.20), fever, and muscle aches.

In this cohort of >6,000 healthcare system and academic medical center employees early in the pandemic, community exposures, and particularly household exposures, were associated with greater risk of SARS-CoV-2 infection than occupational exposures. This work highlights the importance of COVID-19 prevention in the community and in healthcare settings to prevent COVID-19.

In this study, we sought to determine the prevalence of bloodstream infection (BSI) in severe coronavirus disease 2019 (COVID-19) patients and to determine the risk factors of BSI in critical COVID-19 patients.

Retrospective, descriptive study between March 2020 and January 2021.

An 1,007-bed university hospital.

Patients who were hospitalized due to severe COVID-19 disease and had an aerobic blood culture taken at least once during hospitalization

Case definitions were made according to National Institutes of Health clinical definitions. According to the blood culture results, the patients were grouped as with and without BSIs, and compared for BSIs risk factors.

In total, 195 patients were included in the study. Blood culture positivity was detected in 76 (39.0%) of 196 patients. Excluding blood culture positivity considered as contamination, the prevalence of BSI in all severe COVID-19 cases was 18.5% (n = 36). In intensive care unit patients the prevalence of BSI was 30.6% (n = 26). In multivariate analyses, central venous catheter (odds ratio [OR], 8.17; 95% confidence interval [CI], 2.46–27.1; P < .01) and hospitalization in the multibed intensive care unit (OR, 4.28; 95% CI, 1.28–14.3; P < .01) were risk factors associated with the acquisition of BSI.

The prevalence of BSI in COVID-19 patients is particularly high in critically ill patients. The central venous catheter and multibed intensive care follow-up are risk factors for BSI. BSIs can be reduced by increasing compliance to infection control measures and central venous catheter insertion-care procedures. The use of single-bed intensive care units where compliance can be achieved more effectively is important for the prevention of BSIs.

To demonstrate that a syndromic stewardship intervention can safely reduce antipseudomonal antibiotic use in the treatment of inpatient diabetic foot infections (DFIs).

From November 2017 through March 2018, we performed an antimicrobial stewardship intervention that included creation of a DFI best-practice guideline, implementation of an electronic medical record order set, and targeted education of key providers. We conducted a retrospective before-and-after study evaluating guideline adherent antipseudomonal antibiotic use 1 year before and after the intervention using interrupted time-series analysis.

University of Nebraska Medical Center, a 718-bed academic medical center in Omaha, Nebraska.

The study included 193 adults aged ≥19 years (105 in the preintervention group and 88 in the postintervention group) admitted to non–intensive care units whose primary reason for antibiotic treatment was diabetic foot infection (DFI).

Guideline-adherent use of antipseudomonal antibiotics increased from 39% before the intervention to 68% after the intervention (P ≤ .0001). Antipseudomonal antibiotic use decreased from 538 days of therapy (DOT) per 1,000 DFI patient days (PD) before the intervention to 272 DOT per 1,000 DFI PD after the intervention (P < .0001), with a statistically significant decrease in both level of use and slope of change. We did not detect any changes in length of stay, readmission, amputation rate, subsequent positive Clostridioides difficile testing, or mortality.

Our 3-component intervention of guideline creation, implementation of an order set, and targeted education was associated with a significant decrease in antipseudomonal antibiotic use in the management of inpatient DFIs. DFIs are common and should be considered as opportunities for syndromic stewardship intervention.

Assess turnaround time (TAT) and cost-benefit of on-site C. auris screening and its impact on length of stay (LOS) and costs compared to reference laboratories.

Before-and-after retrospective cohort study.

Large-tertiary medical center.

We validated an on-site polymerase chain reaction-based testing platform for C. auris and retrospectively reviewed hospitalized adults who screened negative before and after platform implementation. We constructed multivariable models to assess the association of screening negative with hospital LOS/cost in the pre and postimplementation periods. We adjusted for confounders such as demographics and indwelling device use, and compared TATs for all samples tested.

The sensitivity and specificity of the testing platform were 100% and 98.11%, respectively, compared to send-out testing. The clinical cohort included 287 adults in the pre and 1,266 postimplementation period. The TAT was reduced by more than 2 days (3 (interquartile range (IQR): 2.0, 7.0) vs 0.42 (IQR: 0.24, 0.81), p < 0.001). Median LOS was significantly lower in the postimplementation period; however, this was no longer evident after adjustment. In relation to total cost, the time period had an effect of $6,965 (95% CI: −$481, $14,412); p = 0.067) on reducing the cost. The median adjusted total cost per patient was $7,045 (IQR: $3,805, $13,924) less in the post vs the preimplementation period.

Our assessment did not find a statistically significant change in LOS, nevertheless, on-site testing was not cost-prohibitive for the institution. The value of on-site testing may be supported if an institutional C. auris reduction strategy emphasizes faster TATs.

We sought to determine whether an electronic hand hygiene (HH) system could monitor HH compliance at similar rates to direct human observation.

This 4-year proof-of-concept study was conducted in an intensive care unit (ICU) of a private tertiary-care hospital in São Paulo, Brazil, where electronic HH systems were installed in 2 rooms. HH compliance was reported respectively using direct observation and electronic counter devices with an infrared system for detecting HH opportunities.

In phase 1, HH compliance by human observers was 56.3% (564 of 1,001 opportunities), while HH compliance detected by the electronic observer was 51.0% (515 of 1,010 opportunities). In phase 2, human observers registered 484 HH opportunities with a HH compliance rate of 64.7% (313 of 484) versus 70.6% (346 of 490) simultaneously detected by the electronic system. In addition, an enhanced HH electronic system monitored activity 24 hours per day and HH compliance without the presence of a human observer was 40.3% (10,642 of 26,421 opportunities), providing evidence for the Hawthorne effect.

The electronic HH monitoring system had good correlation with human HH observation, but compliance was remarkably lower when human observers were not present due to the Hawthorne effect (25%–30% absolute difference). Electronic monitoring systems can replace direct observation and can markedly reduce the Hawthorne effect.

Coronavirus disease 2019 (COVID-19) has made it imperative to focus on strategies to improve hand hygiene to minimize threats of viral transmission in hospitals.

We investigated the potential of using ultraviolet (UV) light as a visual tool in hand-hygiene education to bring awareness of individual handwashing effectiveness to healthcare workers.

In 2020, 117 individuals participated in the simulation and completed surveys on proper handwashing technique. Of these, 114 were first-year residents and fellows. Surveys of confidence in hand hygiene were obtained before and after formal hand-hygiene education utilizing UV light with Glo Germ lotion. The UV light and Glo Germ lotion were used to identify deficiencies in individual handwashing technique.

With a total response rate of 97.4%, first-year residents and fellows demonstrated a significant decrease in handwashing confidence in pre- and posteducation surveys. Study participants who had had formal hand-hygiene training in the previous 3 years also indicated confidence in hand hygiene similar to those who had not had previous hand-hygiene training. Conclusions: Overall, resident interns and fellows may have falsely elevated their hand-hygiene confidence levels. However, conclusions regarding the confidence of residents and fellows individually could not be made due to sample size. Many healthcare personnel practice improper handwashing techniques, which may be improved with education and training that includes UV light.

Hospitalized neonates are at high risk for hospital-associated bloodstream infections (HA-BSI) and require locally contextualized interventions to prevent HA-BSI.

The Preventing Infections in Neonates (PIN) collaborative aimed to reach a 50% decrease in neonatal HA-BSI rates for a 27-bed Level IV neonatal intensive care unit (NICU). Using quality improvement (QI) methodologies, a multidisciplinary cross-cultural collaborative implemented phased and bundled interventions from July 2017 to September 2019. Descriptive statistics and statistical process control charts were used to analyze infection rates.

There were 916 admissions, 19,812 patient-days, and 4264 central line days in the NICU during the project period. Monthly baseline preintervention HA-BSI median rate was 3.95/1000 patient-days and decreased to 1.73/1000 patient-days (56% change) during the bundled interventions. Quarterly HA-BSI rates also decreased from the preintervention median of 4.5/1000 patient-days to 3.3/1000 patient-days during the intervention period (IRR 0.73; 95%CI 0.39, 1.36). Staff were highly compliant with hand hygiene and environmental cleaning. Through project efforts, compliance with bundle elements increased from 25% at baseline to a peak of 97% for central line (CL) insertion checklists and from 13% to a peak of 56% for CL maintenance checklists.

Unit-based bundled interventions can reduce neonatal HA-BSI in limited resource settings. Future studies can assess similar practices in other units and the impact of the pandemic on interventions to reduce HA-BSIs.

To quantify the economic burden of bacterial antimicrobial resistance in Thailand and estimate potential savings from improving the rate of appropriate empiric treatment, where effective coverage is provided within the first days of infection.

Cost-of-illness study.

A cost-calculator, decision-tree model was developed using published data and records from 3 Thai hospitals for patients hospitalized with antimicrobial-resistant infections between 2015 and 2019. Direct and indirect costs of antimicrobial-resistant infections were assessed over a 5-year time horizon, with outcomes derived separately for cases having received appropriate empiric treatment versus inappropriate empiric treatment. In a real-world scenario, outcomes were estimated using actual rates of inappropriate empiric treatment, and in a hypothetical scenario, outcomes were estimated using decreased rates of inappropriate empiric treatment.

Over 5 years, in-hospital antimicrobial-resistant infections produced costs of approximately Thai baht (THB) 66.4 billion (USD 2.1 billion) in the real-world scenario and THB 65.8 billion (USD 2.1 billion) in the hypothetical scenario (0.9% cost savings relative to the real-world scenario). Most costs were attributable to income loss due to in-hospital mortality (real world: THB 53.7 billion [USD 1.7 billion]; 80.9% of costs; hypothetical: THB 53.2 billion [USD 1.7 billion]; 80.8% of costs) and hospitalization (real world: THB 10.3 billion [USD 330.8 million]; 15.5% of costs; hypothetical: THB 10.2 billion [USD 328.9 million]; 15.5% of costs).

In-hospital antimicrobial-resistant infections produced a substantial economic toll in Thailand. This public health burden could be reduced with a strategy aimed at decreasing the rate of patients receiving inappropriate empiric treatment.