Antimicrobial stewardship programs (ASPs) are effective in developed countries. In this study, we assessed the effectiveness of an infectious disease (ID) physician–driven post-prescription review and feedback as an ASP strategy in India, a low middle-income country (LMIC).

This prospective cohort study was carried out for 18 months in 2 intensive care units of a tertiary-care hospital, consisting of 3 phases: baseline, intervention, and follow up. Each phase spanned 6 months.

Patients aged ≥15 years receiving 48 hours of study antibiotics were recruited for the study.

During the intervention phase, an ID physician reviewed the included cases and gave alternate recommendations if the antibiotic use was inappropriate. Acceptance of the recommendations was measured after 48 hours. The primary outcome of the study was days of therapy (DOT) per 1,000 study patient days (PD).

Overall, 401 patients were recruited in the baseline phase, 381 patients were recruited in the intervention phase, and 379 patients were recruited in the follow-up phase. Antimicrobial use decreased from 831.5 during the baseline phase to 717 DOT per 1,000 PD in the intervention phase (P < .0001). The effect was sustained in the follow-up phase (713.6 DOT per 1,000 PD). De-escalation according to culture susceptibility improved significantly in the intervention phase versus the baseline phase (42.7% vs 23.6%; P < .0001). Overall, 73.3% of antibiotic prescriptions were inappropriate. Recommendations by the ID team were accepted in 60.7% of the cases.

The ID physician–driven implementation of an ASP was successful in reducing antibiotic utilization in an acute-care setting in India.

Implementing antimicrobial stewardship programs (ASPs) can be challenging due to prescriber resistance. Although barriers to implementing new ASPs have been identified, little is known about how prescribers perceive established programs. This information is critical to promoting the sustainability of ASPs.

To identify how prescribers perceive an established pediatric inpatient ASP that primarily utilizes prior authorization.

We conducted a cross-sectional survey administered from February through June 2017 in a large children’s hospital. The survey contained closed- and open-ended questions. Descriptive statistics and thematic content analysis approaches were used to analyze responses.

Of 394 prescribers invited, 160 (41%) responded. Prescribers had an overall favorable impression of the ASP, believing that it improves the quality of care (92.4% agree) and takes their judgment seriously (73.8%). The most common criticism of the ASP was that it threatened efficiency (26.0% agreed). In addition, 68.7% of respondents reported occasionally engaging in workarounds. Analysis of 133 free-text responses revealed that prescribers perceived that interacting with the ASP involved too many phone calls, caused communication breakdowns with the dispensing pharmacy, and led to gaps between approval and dispensing of antibiotics. Reasons given for workarounds included not wanting to change therapy that appears to be working, consultant disagreement with ASP recommendations, and the desire to do everything possible for patients.

Prescribers had a generally favorable opinion of an established ASP but found aspects to be inefficient. They reported engaging in workarounds occasionally for social and emotional reasons. Established ASPs should elicit feedback from frontline prescribers to optimize program impact.

To assess the safety of, and subsequent allergy documentation associated with, an antimicrobial stewardship intervention consisting of test-dose challenge procedures prompted by an electronic guideline for hospitalized patients with reported β-lactam allergies.

Retrospective cohort study.

Large healthcare system consisting of 2 academic and 3 community acute-care hospitals between April 2016 and December 2017.

We evaluated β-lactam antibiotic test-dose outcomes, including adverse drug reactions (ADRs), hypersensitivity reactions (HSRs), and electronic health record (EHR) allergy record updates. HSR predictors were examined using a multivariable logistic regression model. Modification of the EHR allergy record after test doses considered relevant allergy entries added, deleted, and/or specified.

We identified 1,046 test-doses: 809 (77%) to cephalosporins, 148 (14%) to penicillins, and 89 (9%) to carbapenems. Overall, 78 patients (7.5%; 95% confidence interval [CI], 5.9%–9.2%) had signs or symptoms of an ADR, and 40 (3.8%; 95% CI, 2.8%–5.2%) had confirmed HSRs. Most HSRs occurred at the second (ie, full-dose) step (68%) and required no treatment beyond drug discontinuation (58%); 3 HSR patients were treated with intramuscular epinephrine. Reported cephalosporin allergy history was associated with an increased odds of HSR (odds ratio [OR], 2.96; 95% CI, 1.34–6.58). Allergies were updated for 474 patients (45%), with records specified (82%), deleted (16%), and added (8%).

This antimicrobial stewardship intervention using β-lactam test-dose procedures was safe. Overall, 3.8% of patients with β-lactam allergy histories had an HSR; cephalosporin allergy histories conferred a 3-fold increased risk. Encouraging EHR documentation might improve this safe, effective, and practical acute-care antibiotic stewardship tool.

To ascertain opinions regarding etiology and preventability of hospital-onset bacteremia and fungemia (HOB) and perspectives on HOB as a potential outcome measure reflecting quality of infection prevention and hospital care.

Cross-sectional survey.

Hospital epidemiologists and infection preventionist members of the Society for Healthcare Epidemiology of America (SHEA) Research Network.

A web-based, multiple-choice survey was administered via the SHEA Research Network to 133 hospitals.

A total of 89 surveys were completed (67% response rate). Overall, 60% of respondents defined HOB as a positive blood culture on or after hospital day 3. Central line-associated bloodstream infections and intra-abdominal infections were perceived as the most frequent etiologies. Moreover, 61% thought that most HOB events are preventable, and 54% viewed HOB as a measure reflecting a hospital’s quality of care. Also, 29% of respondents’ hospitals already collect HOB data for internal purposes. Given a choice to publicly report central-line–associated bloodstream infections (CLABSIs) and/or HOB, 57% favored reporting either HOB alone (22%) or in addition to CLABSI (35%) and 34% favored CLABSI alone.

Among the majority of SHEA Research Network respondents, HOB is perceived as preventable, reflective of quality of care, and potentially acceptable as a publicly reported quality metric. Further studies on HOB are needed, including validation as a quality measure, assessment of risk adjustment, and formation of evidence-based bundles and toolkits to facilitate measurement and improvement of HOB rates.

Targeted screening for carbapenem-resistant organisms (CROs), including carbapenem-resistant Enterobacteriaceae (CRE) and carbapenemase-producing organisms (CPOs), remains limited; recent data suggest that existing policies miss many carriers.

Our objective was to measure the prevalence of CRO and CPO perirectal colonization at hospital unit admission and to use machine learning methods to predict probability of CRO and/or CPO carriage.

We performed an observational cohort study of all patients admitted to the medical intensive care unit (MICU) or solid organ transplant (SOT) unit at The Johns Hopkins Hospital between July 1, 2016 and July 1, 2017. Admission perirectal swabs were screened for CROs and CPOs. More than 125 variables capturing preadmission clinical and demographic characteristics were collected from the electronic medical record (EMR) system. We developed models to predict colonization probabilities using decision tree learning.

Evaluating 2,878 admission swabs from 2,165 patients, we found that 7.5% and 1.3% of swabs were CRO and CPO positive, respectively. Organism and carbapenemase diversity among CPO isolates was high. Despite including many characteristics commonly associated with CRO/CPO carriage or infection, overall, decision tree models poorly predicted CRO and CPO colonization (C statistics, 0.57 and 0.58, respectively). In subgroup analyses, however, models did accurately identify patients with recent CRO-positive cultures who use proton-pump inhibitors as having a high likelihood of CRO colonization.

In this inpatient population, CRO carriage was infrequent but was higher than previously published estimates. Despite including many variables associated with CRO/CPO carriage, models poorly predicted colonization status, likely due to significant host and organism heterogeneity.

We investigated the risk factors and origins of the first known occurrence of VRE colonization in the neonatal intensive care unit (NICU) at the Canberra Hospital.

A retrospective case-control study.

A 21-bed neonatal intensive care unit (NICU) and a 15-bed special care nursey (SCN) in a tertiary-care adult and pediatric hospital in Australia.

All patients admitted to the NICU and SCN over the outbreak period: January–May 2017. Of these, 14 were colonized with vancomycin-resistant Enterococcus (VRE) and 77 were noncolonized.

Demographic and clinical variables of cases and controls were compared to evaluate potential risk factors for VRE colonization. Whole-genome sequencing of the VRE isolates was used to determine the origin of the outbreak strain.

Swift implementation of wide-ranging infection control measures brought the outbreak under control. Multivariate logistic regression revealed a strong association between early gestational age and VRE colonization (odds ratio [OR], 3.68; 95% confidence interval [CI], 1.94–7.00). Whole-genome sequencing showed the isolates to be highly clonal Enterococcus faecium ST1421 harboring a vanA gene and to be closely related to other ST1421 previously sequenced from the Canberra Hospital and the Australian Capital Territory.

The colonization of NICU patients was with a highly successful clone endemic to the Canberra Hospital likely introduced into the NICU environment from other wards, with subsequent cross-contamination spreading among the neonate patients. Use of routine surveillance screening may have identified colonization at an earlier stage and have now been implemented on a 6-monthly schedule.

We assessed the impact of personal protective equipment (PPE) doffing errors on healthcare worker (HCW) contamination with multidrug-resistant organisms (MDROs).

Prospective, observational study.

The study was conducted at 4 adult ICUs at 1 tertiary-care teaching hospital.

HCWs who cared for patients on contact precautions for methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococci, or multidrug-resistant gram-negative bacilli were enrolled. Samples were collected from standardized areas of patient body, garb sites, and high-touch environmental surfaces in patient rooms. HCW hands, gloves, PPE, and equipment were sampled before and after patient interaction. Research personnel observed PPE doffing and coded errors based on CDC guidelines.

We enrolled 125 HCWs; most were nurses (66.4%) or physicians (19.2%). During the study, 95 patients were on contact precautions for MRSA. Among 5,093 cultured sites (HCW, patient, environment), 652 (14.7%) yielded the target MDRO. Moreover, 45 HCWs (36%) were contaminated with the target MDRO after patient interactions, including 4 (3.2%) on hands and 38 (30.4%) on PPE. Overall, 49 HCWs (39.2%) made multiple doffing errors and were more likely to have contaminated clothes following a patient interaction (risk ratio [RR], 4.69; P = .04). All 4 HCWs with hand contamination made doffing errors. The risk of hand contamination was higher when gloves were removed before gowns during PPE doffing (RR, 11.76; P = .025).

When caring for patients on CP for MDROs, HCWs appear to have differential risk for hand contamination based on their method of doffing PPE. An intervention as simple as reinforcing the preferred order of doffing may reduce HCW contamination with MDROs.

We longitudinally observed and assessed the impact of the operating room (OR) staff movements and door openings on surrogates of the exogenous infectious risk using a new technology system.

This multicenter observational study included 13 ORs from 10 hospitals, performing planned cardiac and orthopedic surgery (total hip or knee replacement). Door openings during the surgical procedure were obtained from data collected by inertial sensors fixed on the doors. Intraoperative staff movements were captured by a network of 8 infrared cameras. For each surgical procedure, 3 microbiological air counts, longitudinal particles counts, and 1 bacteriological sample of the wound before skin closure were performed. Statistics were performed using a linear mixed model for longitudinal data.

We included 34 orthopedic and 25 cardiac procedures. The median frequency of door openings from incision to closure was independently associated with an increased log10 0.3 µm particle (ß, 0.03; standard deviation [SD], 0.01; P = .01) and air microbial count (ß, 0.07; SD, 0.03; P = .03) but was not significantly correlated with the wound contamination before closure (r = 0.13; P = .32). The number of persons (ß, −0.08; SD, 0.03; P < .01), and the cumulated movements by the surgical team (ß, 0.0004; SD, 0.0005; P < .01) were associated with log10 0.3 µm particle counts.

This study has demonstrated a previously missing association between intraoperative staff movements and surrogates of the exogenous risk of surgical site infection. Restriction of staff movements and door openings should be considered for the control of the intraoperative exogenous infectious risk.

Surveillance of surgical site infections (SSIs) is important for infection control and is usually performed through retrospective manual chart review. The aim of this study was to develop an algorithm for the surveillance of deep SSIs based on clinical variables to enhance efficiency of surveillance.

Retrospective cohort study (2012–2015).

A Dutch teaching hospital.

We included all consecutive patients who underwent colorectal surgery excluding those with contaminated wounds at the time of surgery. All patients were evaluated for deep SSIs through manual chart review, using the Centers for Disease Control and Prevention (CDC) criteria as the reference standard.

We used logistic regression modeling to identify predictors that contributed to the estimation of diagnostic probability. Bootstrapping was applied to increase generalizability, followed by assessment of statistical performance and clinical implications.

In total, 1,606 patients were included, of whom 129 (8.0%) acquired a deep SSI. The final model included postoperative length of stay, wound class, readmission, reoperation, and 30-day mortality. The model achieved 68.7% specificity and 98.5% sensitivity and an area under the receiver operator characteristic (ROC) curve (AUC) of 0.950 (95% CI, 0.932–0.969). Positive and negative predictive values were 21.5% and 99.8%, respectively. Applying the algorithm resulted in a 63.4% reduction in the number of records requiring full manual review (from 1,606 to 590).

This 5-parameter model identified 98.5% of patients with a deep SSI. The model can be used to develop semiautomatic surveillance of deep SSIs after colorectal surgery, which may further improve efficiency and quality of SSI surveillance.

To address 3 questions: What are the origins of bacteria causing surgical site infections (SSIs)? Is there evidence that the offending bacteria are present at the incision site when surgery begins? What are the estimates of the proportion of SSIs that can be prevented with perioperative control of the microbiome?

Review of the literature, examining recognized sources of bacteria causing surgical site infections.

Specifically, I examined the impact of improved control of the microbiome of the skin and nares on reducing SSIs. The initial effort was to examine the reduction of SSIs linked solely to preoperative skin preparation regimens and to either topical nasal antibiotics or pre- and postoperative nasal antiseptic regimens. To corroborate the concept of the importance of the microbiome, a review of studies showing the relationship of SSIs and marker organisms (eg, Propionobacterium acnes) present at the incision sites was performed. The relationships of SSIs to the microbiome of the skin and nares were summarized.

Depending on key assumptions, ∼70%–95% of all SSIs arise from the microbiome of the patients’ skin or nares. Data from the studies of marker organisms suggest that the infecting bacteria are present at the incision site at the time of surgery.

Almost all SSIs arise from the patient’s microbiome. The occurrence of SSIs can be viewed as a perioperative failure to control the microbiome.