To compare the incidence of surgical site infection (SSI) between cefazolin 3 g and 2 g surgical prophylaxis in patients weighing ≥120 kg that undergo elective colorectal surgery.

A multicenter, retrospective cohort study was performed utilizing a validated database of elective colorectal surgeries in Michigan acute care hospitals. Adults weighing ≥120 kg who received cefazolin and metronidazole for surgical prophylaxis between 7/2012 and 6/2021 were included. The primary outcome was SSI, which was defined as an infection diagnosed within 30 days following the principal operative procedure. Multivariable logistic regression was used to identify variables associated with SSI; the exposure of interest was cefazolin 3 g surgical prophylaxis.

A total of 581 patients were included; of these, 367 (63.1%) received cefazolin 3 g, while 214 (36.8%) received 2 g. Patients who received cefazolin 3 g had less optimal antibiotic timing (324 [88.3%] vs 200 [93.5%]; P = .043) and a higher receipt of at least 1 of the prophylaxis antibiotics after incision (22 [6%] vs 5 [2.3%]; P = .043). There was no SSI difference between cefazolin 3 g and 2 g cohorts (23 [6.3%] vs 16 [7.5%], P = .574). When accounting for age, smoking status, and surgical duration, cefazolin 3 g was not associated with a reduction in SSI (adjOR, .64; 95%CI, .32–1.29).

Surgical prophylaxis with cefazolin 3 g, in combination with metronidazole, was not associated with decreased SSI compared to 2 g dosing in obese patients undergoing elective colorectal surgery.

The study objective was to develop and validate a clinical decision support system (CDSS) to guide clinicians through the diagnostic evaluation of hospitalized individuals with suspected pulmonary tuberculosis (TB) in low-prevalence settings.

The “TBorNotTB” CDSS was developed using a modified Delphi method. The CDSS assigns points based on epidemiologic risk factors, TB history, symptoms, chest imaging, and sputum/bronchoscopy results. Below a set point threshold, airborne isolation precautions are automatically discontinued; otherwise, additional evaluation, including infection control review, is recommended. The model was validated through retrospective application of the CDSS to all individuals hospitalized in the Mass General Brigham system from July 2016 to December 2022 with culture-confirmed pulmonary TB (cases) and equal numbers of age and date of testing-matched controls with three negative respiratory mycobacterial cultures.

104 individuals with TB (cases) and 104 controls were identified. Prior residence in a highly endemic country, positive interferon release assay, weight loss, absence of symptom resolution with treatment for alternative diagnoses, and findings concerning for TB on chest imaging were significant predictors of TB (all P < 0.05). CDSS contents and scoring were refined based on the case–control analysis. The final CDSS demonstrated 100% sensitivity and 27% specificity for TB with an AUC of 0.87.

The TBorNotTB CDSS demonstrated modest specificity and high sensitivity to detect TB even when AFB smears were negative. This CDSS, embedded into the electronic medical record system, could help reduce risks of nosocomial TB transmission, patient-time in airborne isolation, and person-time spent reviewing individuals with suspected TB.

Whole genome sequencing (WGS) can help identify transmission of pathogens causing healthcare-associated infections (HAIs). However, the current gold standard of short-read, Illumina-based WGS is labor and time intensive. Given recent improvements in long-read Oxford Nanopore Technologies (ONT) sequencing, we sought to establish a low resource approach providing accurate WGS-pathogen comparison within a time frame allowing for infection prevention and control (IPC) interventions.

WGS was prospectively performed on pathogens at increased risk of potential healthcare transmission using the ONT MinION sequencer with R10.4.1 flow cells and Dorado basecaller. Potential transmission was assessed via Ridom SeqSphere+ for core genome multilocus sequence typing and MINTyper for reference-based core genome single nucleotide polymorphisms using previously published cutoff values. The accuracy of our ONT pipeline was determined relative to Illumina.

Over a six-month period, 242 bacterial isolates from 216 patients were sequenced by a single operator. Compared to the Illumina gold standard, our ONT pipeline achieved a mean identity score of Q60 for assembled genomes, even with a coverage rate as low as 40×. The mean time from initiating DNA extraction to complete analysis was 2 days (IQR 2–3.25 days). We identified five potential transmission clusters comprising 21 isolates (8.7% of sequenced strains). Integrating ONT with epidemiological data, >70% (15/21) of putative transmission cluster isolates originated from patients with potential healthcare transmission links.

Via a stand-alone ONT pipeline, we detected potentially transmitted HAI pathogens rapidly and accurately, aligning closely with epidemiological data. Our low-resource method has the potential to assist in IPC efforts.

Nursing home (NH) residents have an elevated risk of coronavirus disease 2019 (COVID-19) infection and severe outcomes. However, literature regarding outbreak outcomes at the facility level is limited.

NH outbreaks beginning between March 1, 2020, and February 22, 2022, at facilities under Los Angeles County jurisdiction were assigned to 1 of 6 time periods defined by dominant variants, surges in community transmission, and vaccination levels. Outbreaks were defined as 1 or more NH resident cases with lab-confirmed COVID-19 infection and no periods of 14 or more days between successive COVID-19 resident cases. Outbreak size and duration were the number of NH resident cases and the number of days between the index case(s) and 14 days after the last resident case(s). Rates of severe outcomes were measured per 100 licensed beds among all outbreaks per time period.

44,279 cases were analyzed from 1,587 outbreaks. Median outbreak duration peaked during the first winter surge (39 days; time period 3); median outbreak size per 100 licensed beds peaked in time period 6 (17), after widespread vaccination - during the second winter surge. Hospitalizations and deaths per 100 resident cases fell from 31 and 24 prior to widespread vaccination to 11 and 7, respectively, after.

NH COVID-19 outbreaks may have been affected by vaccine uptake and community transmission levels. Because outbreak size and duration peaked during peak community transmission but severe outcome rates did not, the latter may be preferable to outbreak size and duration as outbreak metrics.

Asymptomatic bacteriuria (ASB) treatment is a common form of antibiotic overuse and diagnostic error. Antibiotic stewardship using the inappropriate diagnosis of urinary tract infection (ID-UTI) measure has reduced ASB treatment in diverse hospitals. However, critical access hospitals (CAHs) have differing resources that could impede stewardship. We aimed to determine if stewardship including the ID-UTI measure could reduce ASB treatment in CAHs.

From October 2022 to July 2023, ten CAHs participated in an Intensive Quality Improvement Cohort (IQIC) program including 3 interventions to reduce ASB treatment: 1) learning labs (ie, didactics with shared learning), 2) mentoring, and 3) data-driven performance reports including hospital peer comparison based on the ID-UTI measure. To assess effectiveness of the IQIC program, change in the ID-UTI measure (ie, percentage of patients treated for a UTI who had ASB) was compared to two non-equivalent control outcomes (antibiotic duration and unjustified fluoroquinolone use).

Ten CAHs abstracted a total of 608 positive urine culture cases. Over the cohort period, the percentage of patients treated for a UTI who had ASB declined (aOR per month = 0.935, 95% CI: 0.873, 1.001, P = 0.055) from 28.4% (range across hospitals, 0%-63%) in the first to 18.6% (range, 0%-33%) in the final month. In contrast, antibiotic duration and unjustified fluoroquinolone use were unchanged (P = 0.768 and 0.567, respectively).

The IQIC intervention, including learning labs, mentoring, and performance reports using the ID-UTI measure, was associated with a non-significant decrease in treatment of ASB, while control outcomes (duration and unjustified fluoroquinolone use) did not change.

Inappropriate diagnosis and treatment of urinary tract infections (UTIs) contribute to antibiotic overuse. The Inappropriate Diagnosis of UTI (ID-UTI) measure uses a standard definition of asymptomatic bacteriuria (ASB) and was validated in large hospitals. Critical access hospitals (CAHs) have different resources which may make ASB stewardship challenging. To address this inequity, we adapted the ID-UTI metric for use in CAHs and assessed the adapted measure’s feasibility, validity, and reliability.

Retrospective observational study

10 CAHs

From October 2022 to July 2023, CAHs submitted clinical information for adults admitted or discharged from the emergency department who received antibiotics for a positive urine culture. Feasibility of case submission was assessed as the number of CAHs achieving the goal of 59 cases. Validity (sensitivity/specificity) and reliability of the ID-UTI definition were assessed by dual-physician review of a random sample of submitted cases.

Among 10 CAHs able to participate throughout the study period, only 40% (4/10) submitted >59 cases (goal); an additional 3 submitted >35 cases (secondary goal). Per the ID-UTI metric, 28% (16/58) of cases were ASB. Compared to physician review, the ID-UTI metric had 100% specificity (ie all cases called ASB were ASB on clinical review) but poor sensitivity (48.5%; ie did not identify all ASB cases). Measure reliability was high (93% [54/58] agreement).

Similar to measure performance in non-CAHs, the ID-UTI measure had high reliability and specificity—all cases identified as ASB were considered ASB—but poor sensitivity. Though feasible for a subset of CAHs, barriers remain.

To understand healthcare workers’ (HCWs) beliefs and practices toward blood culture (BCx) use.

Cross-sectional electronic survey and semi-structured interviews.

Academic hospitals in the United States.

HCWs involved in BCx ordering and collection in adult intensive care units (ICU) and wards.

We administered an anonymous electronic survey to HCWs and conducted semi-structured interviews with unit staff and quality improvement (QI) leaders in these institutions to understand their perspectives regarding BCx stewardship between February and November 2023.

Of 314 HCWs who responded to the survey, most (67.4%) were physicians and were involved in BCx ordering (82.3%). Most survey respondents reported that clinicians had a low threshold to culture patients for fever (84.4%) and agreed they could safely reduce the number of BCx obtained in their units (65%). However, only half of them believed BCx was overused. Although most made BCx decisions as a team (74.1%), a minority reported these team discussions occurred daily (42.4%). A third of respondents reported not usually collecting the correct volume per BCx bottle, half were unaware of the improved sensitivity of 2 BCx sets, and most were unsure of the nationally recommended BCx contamination threshold (87.5%). Knowledge regarding the utility of BCx for common infections was limited.

HCWs’ understanding of best collection practices and yield of BCx was limited.

Diagnostic stewardship of urine cultures from patients with indwelling urinary catheters may improve diagnostic specificity and clinical relevance of the test, but risk of patient harm is uncertain.

We retrospectively evaluated the impact of a computerized clinical decision support tool to promote institutional appropriateness criteria (neutropenia, kidney transplant, recent urologic surgery, or radiologic evidence of urinary tract obstruction) for urine cultures from patients with an indwelling urinary catheter. The primary outcome was a change in catheter-associated urinary tract infection (CAUTI) rate from baseline (34 mo) to intervention period (30 mo, including a 2-mo wash-in period). We analyzed patient-level outcomes and adverse events.

Adjusted CAUTI rate decreased from 1.203 to 0.75 per 1,000 catheter-days (P = 0.52). Of 598 patients triggering decision support, 284 (47.5%) urine cultures were collected in agreement with institutional criteria and 314 (52.5%) were averted. Of 314 patients whose urine cultures were averted, 2 had a subsequent urine culture within 7 days that resulted in a change in antimicrobial therapy and 2 had diagnosis of bacteremia with suspected urinary source, but there were no delays in effective treatment.

A diagnostic stewardship intervention was associated with an approximately 50% decrease in urine culture testing for inpatients with a urinary catheter. However, the overall CAUTI rate did not decrease significantly. Adverse outcomes were rare and minor among patients who had a urine culture averted. Diagnostic stewardship may be safe and effective as part of a multimodal program to reduce unnecessary urine cultures among patients with indwelling urinary catheters.

To determine whether differences exist in antibiotic prescribing for respiratory infections in pediatric urgent cares (PUCs) by patient race/ethnicity, insurance, and language.

Multi-center cohort study.

Nine organizations (92 locations) from 22 states and Washington, DC.

Patients ages 6 months–18 years evaluated April 2022–April 2023, with acute viral respiratory infections, otitis media with effusion (OME), acute otitis media (AOM), pharyngitis, community-acquired pneumonia (CAP), and sinusitis.

We compared the use of first-line (FL) therapy as defined by published guidelines. We used race/ethnicity, insurance, and language as exposures. Multivariable logistic regression models estimated the odds of FL therapy by group.

We evaluated 396,340 ARI encounters. Among all encounters, 351,930 (88.8%) received FL therapy (98% for viral respiratory infections, 85.4% for AOM, 96.0% for streptococcal pharyngitis, 83.6% for sinusitis). OME and CAP had the lowest rates of FL therapy (49.9% and 60.7%, respectively). Adjusted odds of receiving FL therapy were higher in Black Non-Hispanic (NH) (adjusted odds ratio [aOR] 1.53 [1.47, 1.59]), Asian NH (aOR 1.46 [1.40, 1.53], and Hispanic children (aOR 1.37 [1.33, 1.41]), compared to White NH. Additionally, odds of receiving FL therapy were higher in children with Medicaid/Medicare (aOR 1.21 [1.18–1.24]) and self-pay (aOR 1.18 [1.1–1.27]) compared to those with commercial insurance.

This multicenter collaborative showed lower rates of FL therapy for children of the White NH race and those with commercial insurance compared to other groups. Exploring these differences through a health equity lens is important for developing mitigating strategies.

Clostridioides difficile (C. difficile) is one of the most common causes of healthcare-associated infections (HAIs). Elimination of C. difficile spores is difficult as they are resistant to common hospital-grade disinfectants. Copper-impregnated surfaces provide continuous reduction of multiple pathogens, potentially lowering the risk of infections. This manuscript aims to evaluate the efficacy of copper-impregnated surfaces on C. difficile spores.

Control (no copper) coupons and copper coupons containing 20% copper-oxide were inoculated with C. difficile spore loads ranging from 105 to 107 spores, with or without 5% fetal bovine serum soil load. After 4 hours of contact time, the C. difficile spores were recovered, plated on C. difficile growth media, and colony forming units were counted. The efficacy of copper (log10 kill) was estimated using a Bayesian latent variables model.

After 4 hours, unsoiled copper bedrail and copper table coupons at mean spore inoculation resulted in a 97.3% and 96.8% reduction in spore count (1.57 and 1.50 log10 kill, respectively). That of soiled bedrail and table coupons showed a 91.8% and 91.7% reduction (1.10 and 1.10 log10 kill, respectively).

Copper coupons can substantially reduce C. difficile spores after 4 hours, but results vary depending on the initial spore concentration and presence or absence of organic material. Higher initial spore loads or excess organic material may prevent spores from contact with copper surfaces, thus decreasing kill efficacy. Continuous sporicidal effect of copper-impregnated surfaces may decrease spore burden and help prevent transmission of spores.

To upgrade cleaning and disinfection of patient rooms in a crowded emergency department (ED).

Tertiary referral hospital.

Prospective, 3-component, before-and-after intervention study.

Phase 1 consisted of a 4-week baseline determination of ED patient-room cleanliness, using two means: (1) the fluorescence spray, applied before cleaning and assessed subsequently with an ultraviolet lamp. Results are expressed as % of removed spots/all spots (≥7/10 cleaned spots/room was considered clean; (2) ATP swabs obtained after cleaning, which test for presence of residual organic material; readings <45 were considered clean. Phase 2 consisted of revision and reorganization of established cleaning practices. Phase 3 consisted of adding one cleaning person in afternoon/evening shifts, for 4-weeks, during which room cleanliness was assessed as previously described.

Cleanliness of the 79 patient rooms, for which fluorescence tests were available from before and after cleaning for all three phases of the study, increased from a baseline of 50% ± 35 removed spots/all spots, to 61% ± 36 after the first intervention (CI95 -0.6 – 21, P = 0.54) and to 68% ± 35 after the second intervention (CI95 5 - 31, P = 0.004, as compared to the baseline). Subanalysis showed that evening shifts improved most remarkably, from 47% ± 32 (n = 45), to 60% ± 33 (n = 49) to 76%±29 (n = 29), respectively, from baseline through the second and third phase (P = 0.001). ATP testing appeared less sensitive for assessment of cleanliness but confirmed the assessment by fluorescence for overall cleanliness (CI95 1 - 14, P = 0.018).

Our data demonstrate that a two-step intervention significantly improves cleaning in a busy ED.