We quantified hospital-acquired coronavirus disease 2019 (COVID-19) during the early phases of the pandemic, and we evaluated solely temporal determinations of hospital acquisition.

Retrospective observational study during early phases of the COVID-19 pandemic, March 1–November 30, 2020. We identified laboratory-detected severe acute respiratory coronavirus virus 2 (SARS-CoV-2) from 30 days before admission through discharge. All cases detected after hospital day 5 were categorized by chart review as community or unlikely hospital-acquired cases, or possible or probable hospital-acquired cases.

The study was conducted in 2 acute-care hospitals in Chicago, Illinois.

The study included all hospitalized patients including an inpatient rehabilitation unit.

Each hospital implemented infection-control precautions soon after identifying COVID-19 cases, including patient and staff cohort protocols, universal masking, and restricted visitation policies.

Among 2,667 patients with SARS-CoV-2, detection before hospital day 6 was most common (n = 2,612; 98%); detection during hospital days 6–14 was uncommon (n = 43; 1.6%); and detection after hospital day 14 was rare (n = 16; 0.6%). By chart review, most cases after day 5 were categorized as community acquired, usually because SARS-CoV-2 had been detected at a prior healthcare facility (68% of cases on days 6–14 and 53% of cases after day 14). The incidence rates of possible and probable hospital-acquired cases per 10,000 patient days were similar for ICU- and non-ICU patients at hospital A (1.2 vs 1.3 difference, 0.1; 95% CI, −2.8 to 3.0) and hospital B (2.8 vs 1.2 difference, 1.6; 95% CI, −0.1 to 4.0).

Most patients were protected by early and sustained application of infection-control precautions modified to reduce SARS-CoV-2 transmission. Using solely temporal criteria to discriminate hospital versus community acquisition would have misclassified many “late onset” SARS-CoV-2–positive cases.

Coronavirus disease 2019 (COVID-19) hospitalization definitions do not include a disease severity assessment. Thus, we sought to identify a simple and objective mechanism for identifying hospitalized severe cases and to measure the impact of vaccination on trends.

All admissions to a Veterans’ Affairs (VA) hospital, where routine inpatient screening is recommended, between March 1, 2020, and November 22, 2021, with laboratory-confirmed severe acute respiratory coronavirus virus 2 (SARS-CoV-2) were included. Moderate-to-severe COVID-19 was defined as any oxygen supplementation or any oxygen saturation (SpO2) <94% between 1 day before and 2 weeks after the positive SARS-CoV-2 test. Admissions with moderate-to-severe disease were divided by the total number of admissions, and the proportion of admissions with moderate-to-severe COVID-19 was modelled using a penalized spline in a Poisson regression and stratified by vaccination status. Dexamethasone receipt and its correlation with moderate-to-severe cases was also assessed.

Among 67,025 admissions with SARS-CoV-2, the proportion with hypoxemia or supplemental oxygen fell from 64% prior to vaccine availability to 56% by November 2021, driven in part by lower rates in vaccinated patients (vaccinated, 52% versus unvaccinated, 58%). The proportion of cases of moderate-to-severe disease identified using SpO2 levels and oxygen supplementation was highly correlated with dexamethasone receipt (correlation coefficient, 0.95), and increased after July 1, 2021, concurrent with δ (delta) variant predominance.

A simple and objective definition of COVID-19 hospitalizations using SpO2 levels and oxygen supplementation can be used to track pandemic severity. This metric could be used to identify risk factors for severe breakthrough infections, to guide clinical treatment algorithms, and to detect trends in changes in vaccine effectiveness over time and against new variants.

The spatial and temporal extent of severe acute respiratory coronavirus virus 2 (SARS-CoV-2) environmental contamination has not been precisely defined. We sought to elucidate contamination of different surface types and how contamination changes over time.

We sampled surfaces longitudinally within COVID-19 patient rooms, performed quantitative RT-PCR for the detection of SARS-CoV-2 RNA, and modeled distance, time, and severity of illness on the probability of detecting SARS-CoV-2 using a mixed-effects binomial model.

The probability of detecting SARS-CoV-2 RNA in a patient room did not vary with distance. However, we found that surface type predicted probability of detection, with floors and high-touch surfaces having the highest probability of detection: floors (odds ratio [OR], 67.8; 95% credible interval [CrI], 36.3–131) and high-touch elevated surfaces (OR, 7.39; 95% CrI, 4.31–13.1). Increased surface contamination was observed in room where patients required high-flow oxygen, positive airway pressure, or mechanical ventilation (OR, 1.6; 95% CrI, 1.03–2.53). The probability of elevated surface contamination decayed with prolonged hospitalization, but the probability of floor detection increased with the duration of the local pandemic wave.

Distance from a patient’s bed did not predict SARS-CoV-2 RNA deposition in patient rooms, but surface type, severity of illness, and time from local pandemic wave predicted surface deposition.

To determine the impact of various aerosol mitigation interventions and to establish duration of aerosol persistence in a variety of dental clinic configurations.

We performed aerosol measurement studies in endodontic, orthodontic, periodontic, pediatric, and general dentistry clinics. We used an optical aerosol spectrometer and wearable particulate matter sensors to measure real-time aerosol concentration from the vantage point of the dentist during routine care in a variety of clinic configurations (eg, open bay, single room, partitioned operatories). We compared the impact of aerosol mitigation strategies (eg, ventilation and high-volume evacuation (HVE), and prevalence of particulate matter) in the dental clinic environment before, during, and after high-speed drilling, slow–speed drilling, and ultrasonic scaling procedures.

Conical and ISOVAC HVE were superior to standard-tip evacuation for aerosol-generating procedures. When aerosols were detected in the environment, they were rapidly dispersed within minutes of completing the aerosol-generating procedure. Few aerosols were detected in dental clinics, regardless of configuration, when conical and ISOVAC HVE were used.

Dentists should consider using conical or ISOVAC HVE rather than standard-tip evacuators to reduce aerosols generated during routine clinical practice. Furthermore, when such effective aerosol mitigation strategies are employed, dentists need not leave dental chairs fallow between patients because aerosols are rapidly dispersed.

To assess the rate and factors associated with healthcare personnel (HCP) testing positive for severe acute respiratory coronavirus virus 2 (SARS-CoV-2) after an occupational exposure.

Retrospective cohort study.

Academic medical center with sites in Minnesota, Wisconsin, Arizona, and Florida.

HCP with a high or medium risk occupational exposure to a patient or other HCP with SARS-CoV-2.

We reviewed the records of HCP with significant occupational exposures from March 20, 2020, through December 31, 2020. We then performed regression analysis to assess the impact of demographic and occupational variables to assess their impact on the likelihood of testing positive for SARS-CoV-2.

In total, 2,253 confirmed occupational exposures occurred during the study period. Employees were the source for 57.1% of exposures. Overall, 101 HCP (4.5%) tested positive in the postexposure period. Of these, 80 had employee sources of exposure and 21 had patient sources of exposure. The postexposure infection rate was 6.2% when employees were the source, compared to 2.2% with patient sources. In a multivariate analysis, occupational exposure from an employee source had a higher risk of testing positive compared to a patient source (odds ratio [OR], 3.22; 95% confidence interval [CI], 1.72–6.04). Sex, age, high-risk exposure, and HCP role were not associated with an increased risk of testing positive.

The risk of acquiring coronavirus disease 2019 (COVID-19) following a significant occupational exposure has remained relatively low, even in the prevaccination era. Exposure to an infectious coworker carries a higher risk than exposure to a patient. Continued vigilance and precautions remain necessary in healthcare settings.

Healthcare workers (HCWs) not adhering to physical distancing recommendations is a risk factor for acquisition of severe acute respiratory coronavirus virus 2 (SARS-CoV-2). The study objective was to assess the impact of interventions to improve HCW physical distancing on actual distance between HCWs in a real-life setting.

HCWs voluntarily wore proximity beacons to measure the number and intensity of physical distancing interactions between each other in a pediatric intensive care unit. We compared interactions before and after implementing a bundle of interventions including changes to the layout of workstations, cognitive aids, and individual feedback from wearable proximity beacons.

Overall, we recorded 10,788 interactions within 6 feet (∼2 m) and lasting >5 seconds. The number of HCWs wearing beacons fluctuated daily and increased over the study period. On average, 13 beacons were worn daily (32% of possible staff; range, 2–32 per day). We recorded 3,218 interactions before the interventions and 7,570 interactions after the interventions began. Using regression analysis accounting for the maximum number of potential interactions if all staff had worn beacons on a given day, there was a 1% decline in the number of interactions per possible interactions in the postintervention period (incident rate ratio, 0.99; 95% confidence interval, 0.98–1.00; P = .02) with fewer interactions occurring at nursing stations, in workrooms and during morning rounds.

Using quantitative data from wearable proximity beacons, we found an overall small decline in interactions within 6 feet between HCWs in a busy intensive care unit after a multifaceted bundle of interventions was implemented to improve physical distancing.

Understand how the built environment can affect safety and efficiency outcomes during doffing of personal protective equipment (PPE) in the context of coronavirus disease 2019 (COVID-19) patient care.

We conducted (1) field observations and surveys administered to healthcare workers (HCWs) performing PPE doffing, (2) focus groups with HCWs and infection prevention experts, and (3) a with healthcare design experts.

This study was conducted in 4 inpatient units treating patients with COVID-19, in 3 hospitals of a single healthcare system.

The study included 24 nurses, 2 physicians, 1 respiratory therapist, and 2 infection preventionists.

The doffing task sequence and the layout of doffing spaces varied considerably across sites, with field observations showing most doffing tasks occurring around the patient room door and PPE support stations. Behaviors perceived as most risky included touching contaminated items and inadequate hand hygiene. Doffing space layout and types of PPE storage and work surfaces were often associated with inadequate cleaning and improper storage of PPE. Focus groups and the design charrette provided insights on how design affording standardization, accessibility, and flexibility can support PPE doffing safety and efficiency in this context.

There is a need to define, organize and standardize PPE doffing spaces in healthcare settings and to understand the environmental implications of COVID-19–specific issues related to supply shortage and staff workload. Low-effort and low-cost design adaptations of the layout and design of PPE doffing spaces may improve HCW safety and efficiency in existing healthcare facilities.

Healthcare workers (HCWs) are a high-priority group for coronavirus disease 2019 (COVID-19) vaccination and serve as sources for public information. In this analysis, we assessed vaccine intentions, factors associated with intentions, and change in uptake over time in HCWs.

A prospective cohort study of COVID-19 seroprevalence was conducted with HCWs in a large healthcare system in the Chicago area. Participants completed surveys from November 25, 2020, to January 9, 2021, and from April 24 to July 12, 2021, on COVID-19 exposures, diagnosis and symptoms, demographics, and vaccination status.

Of 4,180 HCWs who responded to a survey, 77.1% indicated that they intended to get the vaccine. In this group, 23.2% had already received at least 1 dose of the vaccine, 17.4% were unsure, and 5.5% reported that they would not get the vaccine. Factors associated with intention or vaccination were being exposed to clinical procedures (vs no procedures: adjusted odds ratio [AOR], 1.39; 95% confidence interval [CI], 1.16–1.65) and having a negative serology test for COVID-19 (vs no test: AOR, 1.46; 95% CI, 1.24–1.73). Nurses (vs physicians: AOR, 0.24; 95% CI, 0.17–0.33), non-Hispanic Black (vs Asians: AOR, 0.35; 95% CI, 0.21–0.59), and women (vs men: AOR, 0.38; 95% CI, 0.30–0.50) had lower odds of intention to get vaccinated. By 6-months follow-up, >90% of those who had previously been unsure were vaccinated, whereas 59.7% of those who previously reported no intention of getting vaccinated, were vaccinated.

COVID-19 vaccination in HCWs was high, but variability in vaccination intention exists. Targeted messaging coupled with vaccine mandates can support uptake.

To assess characteristics and perceptions associated with vaccine hesitancy among healthcare workers to increase coronavirus disease 2019 (COVID-19) vaccine uptake in this population.

Cross-sectional quantitative survey.

A not-for-profit healthcare system in southwestern Virginia.

A convenience sample of 2,720 employees of a not-for-profit healthcare system.

Between March 15 and 29, 2021, we conducted an Internet-based survey. Our questionnaire assessed sociodemographic and work-related characteristics, vaccine experience and intentions, agreement with vaccine-related perceptions, the most important reasons for getting or not getting vaccinated, and trusted sources of information about COVID-19. We used χ2 analyses to assess the relationship between vaccine hesitancy and both HCW characteristics and vaccine-related perceptions.

Overall, 18% of respondents were classified as vaccine hesitant. Characteristics significantly associated with hesitancy included Black race, younger age, not having a high-risk household member, and prior personal experience with COVID-19 illness. Vaccine hesitancy was also significantly associated with many vaccine-related perceptions, including concerns about short-term and long-term side effects and a belief that the vaccines are not effective. Among vaccine-acceptant participants, wanting to protect others and wanting to help end the pandemic were the most common reasons for getting vaccinated. Personal physicians were cited most frequently as trusted sources of information about COVID-19 among both vaccine-hesitant and vaccine-acceptant respondents.

Educational interventions to decrease vaccine hesitancy among healthcare workers should focus on alleviating safety concerns, emphasizing vaccine efficacy, and appealing to a sense of duty. Such interventions should target younger adult audiences. Personal physicians may also be an effective avenue for reducing hesitancy among their patients through patient-centered discussions.

Although a growing number of healthcare facilities are implementing healthcare personnel (HCP) coronavirus disease 2019 (COVID-19) vaccination requirements, vaccine exemption request management as a part of such programs is not well described.

Cross-sectional survey.

Infectious disease (ID) physician members of the Emerging Infections Network with infection prevention or hospital epidemiology responsibilities.

Eligible persons were sent a web-based survey focused on hospital plans and practices around exemption allowances from HCP COVID-19 vaccine requirements.

Of the 695 ID physicians surveyed, 263 (38%) responded. Overall, 160 respondent institutions (92%) allowed medical exemptions, whereas 132 (76%) allowed religious exemptions. In contrast, only 14% (n = 24) allowed deeply held personal belief exemptions. The types of medical exemptions allowed varied considerably across facilities, with allergic reactions to the vaccine or its components accepted by 145 facilities (84%). For selected scenarios commonly used as the basis for religious and deeply held personal belief exemption requests, 144 institutions (83%) would not approve exemptions focused on concerns regarding right of consent or violations of freedom of personal choice, and 140 institutions (81%) would not approve exemptions focused on introducing foreign substances into one’s body or the sanctity of the body. Most respondents noted plans for additional infection prevention interventions for HCP who received an exemption for COVID-19 vaccination.

Although many respondent institutions allowed exemptions from HCP COVID-19 vaccination requirements, the types of exemptions allowed and how the exemption programs were structured varied widely.

Exposure to infected healthcare workers (HCWs) is a source of hospital-acquired (HA) influenza. We estimated the risk of HA influenza for hospitalized patients by rate of influenza vaccine coverage (IVC) of HCWs.

A case–case negative control study nested in a prospective cohort was conducted in 2 French university hospitals during 2 influenza seasons. Each inpatient with influenza-like illness (ILI) provided a nasal swab sample that was systematically analyzed for influenza virus by polymerase chain reaction (PCR) testing. An HA influenza case was a patient with a virological confirmation of influenza with onset of symptoms ≥72 hours after admission to the ward. The IVC rate of HCWs in each participating ward was calculated from the data provided by the occupational health departments. A mixed-effect logistic regression was performed with adjustments on patient sex, age, the presence of a potential source of influenza on the ward in the 5 days prior to the start of the ILI, type of ward and influenza season.

The overall HA influenza attack rate was 1.9 per 1,000 hospitalized patients. In total, 24 confirmed HA influenza cases and 141 controls were included. The crude odds ratio (OR) of HA influenza decreased from 0.52 (95% confidence interval [CI], 0.21–1.29) to 0.14 (95% CI, 0.03–0.63) when the IVC of HCWs increased from 20% to 40%. After adjustment, IVC ≥40% was associated with a risk reduction of HA influenza (aOR, 0.07; 95% CI, 0.01–0.78).

Considering a limited sample size, influenza vaccination of HCWs is highly suggestive of HA flu prevention among hospitalized patients.

Trial Registration: clinicaltrials.gov identifier: NCT02198638.

Temporal overlap of the Atlantic hurricane season and seasonal influenza vaccine rollout has the potential to result in delays or disruptions of vaccination campaigns. We documented seasonal influenza vaccination behavior over a 5-year period and explored associations between flooding following Hurricane Harvey and timing and uptake of vaccines, as well as how the impacts of Hurricane Harvey on vaccination vary by race, wealth, and rurality.

Retrospective cohort analysis.

Texas counties affected by Hurricane Harvey.

Active users of the Veterans’ Health Administration in 2017.

We used geocoded residential address data to assess flood exposure status following Hurricane Harvey. Days to receipt of seasonal influenza vaccines were calculated for each year from 2014 to 2019. Proportional hazards models were used to determine how likelihood of vaccination varied according to flood status as well as the race, wealth, and rural–urban residence of patients.

The year of Hurricane Harvey was associated with a median delay of 2 weeks to vaccination and lower overall vaccination than in prior years. Residential status in flooded areas was associated with lower hazards of influenza vaccination in all years. White patients had higher proportional hazards of influenza vaccination than non-White patients, though this attenuated to 6.39% (hazard ratio [HR], 1.0639; 95% confidence interval [CI], 1.034–1.095) in the hurricane. year.

Receipt of seasonal influenza vaccination following regional exposure to the effects of Hurricane Harvey was delayed among US veterans. White, non–low-income, and rural patients had higher likelihood of vaccination in all years of the study, but these gaps narrowed during the hurricane year.

To describe the epidemiology of patients with nonintestinal carbapenem-resistant Enterobacterales (CRE) colonization and to compare clinical outcomes of these patients to those with CRE infection.

A secondary analysis of Consortium on Resistance Against Carbapenems in Klebsiella and other Enterobacteriaceae 2 (CRACKLE-2), a prospective observational cohort.

A total of 49 US short-term acute-care hospitals.

Patients hospitalized with CRE isolated from clinical cultures, April, 30, 2016, through August 31, 2017.

We described characteristics of patients in CRACKLE-2 with nonintestinal CRE colonization and assessed the impact of site of colonization on clinical outcomes. We then compared outcomes of patients defined as having nonintestinal CRE colonization to all those defined as having infection. The primary outcome was a desirability of outcome ranking (DOOR) at 30 days. Secondary outcomes were 30-day mortality and 90-day readmission.

Of 547 patients with nonintestinal CRE colonization, 275 (50%) were from the urinary tract, 201 (37%) were from the respiratory tract, and 71 (13%) were from a wound. Patients with urinary tract colonization were more likely to have a more desirable clinical outcome at 30 days than those with respiratory tract colonization, with a DOOR probability of better outcome of 61% (95% confidence interval [CI], 53%–71%). When compared to 255 patients with CRE infection, patients with CRE colonization had a similar overall clinical outcome, as well as 30-day mortality and 90-day readmission rates when analyzed in aggregate or by culture site. Sensitivity analyses demonstrated similar results using different definitions of infection.

Patients with nonintestinal CRE colonization had outcomes similar to those with CRE infection. Clinical outcomes may be influenced more by culture site than classification as “colonized” or “infected.”

To evaluate hospital-level variation in using first-line antibiotics for Clostridioides difficile infection (CDI) based on the burden of laboratory-identified (LabID) CDI.

Using data on hospital-level LabID CDI events and antimicrobial use (AU) for CDI (oral/rectal vancomycin or fidaxomicin) submitted to the National Healthcare Safety Network in 2019, we assessed the association between hospital-level CDI prevalence (per 100 patient admissions) and rate of CDI AU (days of therapy per 1,000 days present) to generate a predicted value of AU based on CDI prevalence and CDI test type using negative binomial regression. The ratio of the observed to predicted AU was then used to identify hospitals with extreme discordance between CDI prevalence and CDI AU, defined as hospitals with a ratio outside of the intervigintile range.

Among 963 acute-care hospitals, rate of CDI prevalence demonstrated a positive dose–response relationship with rate of CDI AU. Compared with hospitals without extreme discordance (n = 902), hospitals with lower-than-expected CDI AU (n = 31) had, on average, fewer beds (median, 106 vs 208), shorter length of stay (median, 3.8 vs 4.2 days), and higher proportion of undergraduate or nonteaching medical school affiliation (48% vs 39%). Hospitals with higher-than-expected CDI AU (n = 30) were similar overall to hospitals without extreme discordance.

The prevalence rate of LabID CDI had a significant dose–response association with first-line antibiotics for treating CDI. We identified hospitals with extreme discordance between CDI prevalence and CDI AU, highlighting potential opportunities for data validation and improvements in diagnostic and treatment practices for CDI.

Research on complications with peripherally inserted central catheter (PICC) lines that are placed for the treatment of prosthetic joint infection (PJI) after total hip arthroplasty (THA) and total knee arthroplasty (TKA) is scarce. We investigated the timing, frequency, and risk factors for PICC complications during treatment of PJI after THA and TKA.

We retrospectively queried an institutional database for THA and TKA patients from January 2015 through December 2020 that developed a PJI and required PICC placement at an academic, tertiary-care referral center.

The study included 889 patients (48.3% female) with a mean age of 64.6 years (range, 18.7–95.2) who underwent 435 THAs and 454 TKAs that were revised for PJI. The cohort had 275 90-day ED visits (30.9%), and 51 (18.5%) were PICC related. The average time from discharge to PICC ED visit was 26.2 days (range, 0.3–89.4). The most common reasons for a 90-day ED visit were issues related to the joint replacement or wound site (musculoskeletal or MSK; n = 116, 42.2%) and PICC complaints (n = 51, 18.5%). A multivariable logistic regression demonstrated that non-White race (odds ratio [OR], 2.24; 95% confidence interval [CI], 1.24–4.04; P = .007) and younger age (OR, 0.98; 95% CI, 0.95–1.00; P = .035) were associated with PICC-related ED visits. Malposition/readjustment (41.2%) and occlusion (35.3%) were the most common PICC complications leading to ED presentation.

PICC complications are common after PJI treatment, accounting for nearly 20% of 90-day ED visits.

Insertion of an external ventricular drain (EVD) is a common neurosurgical procedure which may lead to serious complications including infection. Some risk factors associated with EVD infection are well established. Others remain less certain, including specific indications for placement, prior neurosurgery, and prior EVD placement.

To identify risk factors for EVD infections.

We reviewed all EVD insertions at our institution from March 2015 through May 2019 following implementation of a standardized infection control protocol for EVD insertion and maintenance. Cox regression was used to identify risk factors for EVD infections.

479 EVDs placed in 409 patients met inclusion criteria, and 9 culture-positive infections were observed during the study period. The risk of infection within 30 days of EVD placement was 2.2% (2.3 infections/1,000 EVD days). Coagulase-negative staphylococci were identified in 6 of the 9 EVD infections). EVD infection led to prolonged length of stay post–EVD-placement (23 days vs 16 days; P = .045). Cox regression demonstrated increased infection risk in patients with prior brain surgery associated with cerebrospinal fluid (CSF) diversion (HR, 8.08; 95% CI, 1.7–39.4; P = .010), CSF leak around the catheter (HR, 21.0; 95% CI, 7.0–145.1; P = .0007), and insertion site dehiscence (HR, 7.53; 95% CI, 1.04–37.1; P = .0407). Duration of EVD use >7 days was not associated with infection risk (HR, 0.62; 95% CI, 0.07–5.45; P = .669).

Risk factors associated with EVD infection include prior brain surgery, CSF leak, and insertion site dehiscence. We found no significant association between infection risk and duration of EVD placement.

During infectious disease outbreaks or pandemics, an increased demand for surgical N95s that create shortages and necessitate the use of alternative National Institute for Occupational Safety and Health (NIOSH)–approved respirators that do not meet the Food and Drug Administration (FDA) additional requirements. The objective of this research was to quantify the level of bacterial contamination resulting from wearing NIOSH-approved respirators lacking the additional protections afforded by surgical N95s.

Participants performed simulated healthcare tasks while wearing 5 different respirators approved by the NIOSH. Sterile field contamination resulting from use of a surgical mask cleared by the FDA served as a baseline for comparison with the NIOSH-approved respirators.

The bacterial contamination produced by participants wearing the N95 filtering facepiece respirators (FFRs) without an exhalation valve, the powered air-purifying respirators (PAPRs) with an assigned protection factor of 25 or 1,000 was not significantly different compared to the contamination resulting from wearing the surgical mask. The bacterial contamination resulting from wearing the N95 FFR with an exhalation valve and elastomeric half-mask respirator (EHMR) with an exhalation valve was found to be statistically significantly higher than the bacterial contamination resulting from wearing the surgical mask.

Overall, NIOSH-approved respirators without exhalation valves maintain a sterile field as well as a surgical mask. These findings inform respiratory guidance on the selection of respirators where sterile fields are needed during shortages of surgical N95 FFRs.

To describe the association between duration of antimicrobial prophylaxis (AMP) and 30-day surgical site infection (SSI), 7-day acute kidney injury (AKI), 90-day Clostridioides difficile infection (CDI), prolonged hospitalization, and 30-day reoperation after lumbar spine surgery for noninfectious indications, and to report adherence to current guidelines.

Survey.

The study cohort comprised 6,198 patients who underwent lumbar spine surgery for noninfectious indications across 137 Veterans’ Health Administration surgery centers between 2016 and 2020.

Used univariate and multivariate logistic regression to determine the association between type and duration of AMP with 30-day SSI, 7-day AKI, 90-day CDI, prolonged hospitalization, and 30-day reoperation.

Only 1,160 participants (18.7%) received the recommended duration of AMP. On multivariate analysis, the use of multiple prophylactic antimicrobials was associated with increased odds of 90-day CDI (adjusted odds ratio [aOR], 5.5; 95% confidence interval [CI], 1.1–28.2) and 30-day reoperation (aOR, 2.3; 95% CI, 1.2–4.4). Courses of antimicrobials ≥3 days were associated with increased odds of prolonged hospitalization (aOR,1.8; 95% CI, 1.4–2.3) and 30-day reoperation (aOR, 3.5; 95% CI, 2.2–5.7). In univariate analysis, increasing days of AMP was associated with a trend toward increasing odds of 90-day CDI (cOR, 1.4; 95% CI, 1.0–1.8 per additional day; P = .056).

Longer courses of AMP after lumbar spine surgery were associated with higher odds of CDI, prolonged hospitalization, and reoperation, but not with lower odds of SSI. However, adherence to the recommended duration of AMP is very low, hinting at a wide evidence-to-practice gap that needs to be addressed by spine surgeons and antimicrobial stewardship programs.

To describe national antibiotic prescribing for acute gastroenteritis (AGE).

Ambulatory care.

We included visits with diagnoses for bacterial and viral gastrointestinal infections from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey (NAMCS/NHAMCS; 2006–2015) and the IBM Watson 2014 MarketScan Commercial Claims and Encounters Database. For NAMCS/NHAMCS, we calculated annual percentage estimates and 99% confidence intervals (CIs) of visits with antibiotics prescribed; sample sizes were too small to calculate estimates by pathogen. For MarketScan, we used Poisson regression to calculate the percentage of visits with antibiotics prescribed and 95% CIs, including by pathogen.

We included 10,210 NAMCS/NHAMCS AGE visits; an estimated 13.3% (99% CI, 11.2%–15.4%) resulted in antibiotic prescriptions, most frequently fluoroquinolones (28.7%; 99% CI, 21.1%–36.3%), nitroimidazoles (20.2%; 99% CI, 14.0%–26.4%), and penicillins (18.9%; 99% CI, 11.6%–26.2%). In NAMCS/NHAMCS, antibiotic prescribing was least frequent in emergency departments (10.8%; 99% CI, 9.5%–12.1%). Among 1,868,465 MarketScan AGE visits, antibiotics were prescribed for 13.8% (95% CI, 13.7%−13.8%), most commonly for Yersinia (46.7%; 95% CI, 21.4%–71.9%), Campylobacter (44.8%; 95% CI, 41.5%–48.1%), Shigella (39.7%; 95% CI, 35.9%–43.6%), typhoid or paratyphoid fever (32.7%; (95% CI, 27.2%–38.3%), and nontyphoidal Salmonella (31.7%; 95% CI, 29.5%–33.9%). Antibiotics were prescribed for 12.3% (95% CI, 11.7%–13.0%) of visits for viral gastroenteritis.

Overall, ∼13% of AGE visits resulted in antibiotic prescriptions. Antibiotics were unnecessarily prescribed for viral gastroenteritis and some bacterial infections for which antibiotics are not recommended. Antibiotic stewardship assessments and interventions for AGE are needed in ambulatory settings.

Asynchronous virtual patient care is increasingly used; however, the effectiveness of virtually delivering guideline-concordant care in conjunction with antibiotic stewardship initiatives remains uncertain. We developed a bundled stewardship intervention to improve antibiotic use in E-visits for upper respiratory tract infections (URTIs).

In this before-and-after study, adult patients who completed E-visits for “cough,” “flu,” or “sinus symptoms” at Michigan Medicine between January 1, 2018, and September 30, 2020, were included. Patient demographics, diagnoses, and antibiotic details were collected. The multifaceted intervention occurred over 6 months. Segmented linear regression was performed to estimate the effect of the intervention on appropriate antibiotic use for URTI diagnoses (defined as no antibiotic prescribed) and sinusitis (defined as guideline-concordant antibiotic selection and duration). Regression lines were fit to data before the bundled intervention (January 2019) and after the bundled intervention (May 2019).

In total, 5,151 E-visits were included. The intervention decreased the number of visits for flu, cough, or sinus symptoms prescribed antibiotics from 43.2% to 28.9% (P < .001). Guideline concordance of antibiotic prescriptions improved following the intervention: first-line amoxicillin-clavulanate rose from 37.9% of prescriptions to 66.1% of prescriptions (P < .001), second-line doxycycline rose from 13.8% to 22.7% (P < .001); and median duration of antibiotics decreased from 10 days to 5 days (P < .001).

A multifaceted stewardship bundle for E-visits involving both changes in the EMR and audit and feedback improved guideline-concordant antibiotic use for URTIs. This approach can aid stewardship efforts in the ambulatory care setting with regard to telemedicine.