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.

To determine antibiotic prescribing appropriateness for respiratory tract diagnoses (RTD) by season.

Retrospective cohort study.

Primary care practices in a university health system.

Patients who were seen at an office visit with diagnostic code for RTD.

Office visits for the entire cohort were categorized based on ICD-10 codes by the likelihood that an antibiotic was indicated (tier 1: always indicated; tier 2: sometimes indicated; tier 3: rarely indicated). Medical records were reviewed for 1,200 randomly selected office visits to determine appropriateness. Based on this reference standard, metrics and prescriber characteristics associated with inappropriate antibiotic prescribing were determined. Characteristics of antibiotic prescribing were compared between winter and summer months.

A significantly greater proportion of RTD visits had an antibiotic prescribed in winter [20,558/51,090 (40.2%)] compared to summer months [11,728/38,537 (30.4%)][standardized difference (SD) = 0.21]. A significantly greater proportion of winter compared to summer visits was associated with tier 2 RTDs (29.4% vs 23.4%, SD = 0.14), but less tier 3 RTDs (68.4% vs 74.4%, SD = 0.13). A greater proportion of visits in winter compared to summer months had an antibiotic prescribed for tier 2 RTDs (80.2% vs 74.2%, SD = 0.14) and tier 3 RTDs (22.9% vs 16.2%, SD = 0.17). The proportion of inappropriate antibiotic prescribing was higher in winter compared to summer months (72.4% vs 62.0%, P < .01).

Increases in antibiotic prescribing for RTD visits from summer to winter were likely driven by shifts in diagnoses as well as increases in prescribing for certain diagnoses. At least some of this increased prescribing was inappropriate.

To estimate the association between in situ steroids and spine surgical-site infections (SSIs), assessing spinal instrumentation as an effect modifier and adjusting for confounders.

Case–control study.

Rural academic medical center.

We identified 1,058 adults undergoing posterior fusion and laminectomy procedures as defined by the National Healthcare Safety Network without a pre-existing SSI between January 2020 and December 2021. We identified 26 SSI as cases and randomly selected 104 controls from the remaining patients without SSI.

The primary exposure was the intraoperative administration of methylprednisolone in situ (ie, either in the wound bed or as an epidural injection). The primary outcome was a clinical diagnosis of SSI within 6 months of a patient’s first spine surgery at our facility. We quantified the association between the exposure and outcome using logistic regression, using a product term to assess for effect modification by spinal instrumentation and the change-in-estimate approach to select significant confounders.

Adjusting for Charlson comorbidity index and malignancy, in situ steroids were significantly associated with spine SSI relative to no in situ steroids for instrumented procedures (adjusted odds ratio [aOR], 9.93; 95% confidence interval [CI], 1.54–64.0), but they were not associated with spine SSIs among noninstrumented procedures (aOR, 0.86; 95% CI, 0.15–4.93).

In situ steroids were significantly associated with spine SSI among instrumented procedures. The benefits of in situ steroids for pain management following spine surgery should be weighed against the risk of SSI, especially for instrumented procedures.

To determine metrics and provider characteristics associated with inappropriate antibiotic prescribing for respiratory tract diagnoses (RTDs).

Retrospective cohort study.

Primary care practices in a university health system.

Patients seen by an attending physician or advanced practice provider (APP) at their primary care office visit with International Classification of Disease, Tenth Revision, Clinical Modification (ICD-10-CM)–coded RTDs.

Medical records were reviewed for 1,200 randomly selected office visits in which an antibiotic was prescribed to determine appropriateness. Based on this gold standard, metrics and provider characteristics associated with inappropriate antibiotic prescribing were determined.

Overall, 69% of antibiotics were inappropriate. Metrics utilizing prespecified RTDs most strongly associated with inappropriate prescribing were (1) proportion prescribing for RTDs for which antibiotics are almost never required (eg, bronchitis) and (2) proportion prescribing for any RTD. Provider characteristics associated with inappropriate antibiotic prescribing were APP versus physician (72% vs 58%; P = .02), family medicine versus internal medicine (76% vs 63%; P = .01), board certification 1997 or later versus board certification before 1997 (75% vs 63%; P = .02), nonteaching versus teaching practice (73% vs 51%; P < .01), and nonurban vs urban practice (77% vs 57%; P < .01).

Metrics utilizing proportion prescribing for RTDs for which antibiotics are almost never required and proportion prescribing for any RTD were most strongly associated with inappropriate prescribing. APPs and clinicians with family medicine training, with board certification 1997 or later, and who worked in nonteaching or nonurban practices had higher proportions of inappropriate prescribing. These findings could inform design of interventions to improve prescribing and could represent an efficient way to track inappropriate prescribing.

To determine the impact of total household decolonization with intranasal mupirocin and chlorhexidine gluconate body wash on recurrent methicillin-resistant Staphylococcus aureus (MRSA) infection among subjects with MRSA skin and soft-tissue infection.

Three-arm nonmasked randomized controlled trial.

Five academic medical centers in Southeastern Pennsylvania.

Adults and children presenting to ambulatory care settings with community-onset MRSA skin and soft-tissue infection (ie, index cases) and their household members.

Enrolled households were randomized to 1 of 3 intervention groups: (1) education on routine hygiene measures, (2) education plus decolonization without reminders (intranasal mupirocin ointment twice daily for 7 days and chlorhexidine gluconate on the first and last day), or (3) education plus decolonization with reminders, where subjects received daily telephone call or text message reminders.

Owing to small numbers of recurrent infections, this analysis focused on time to clearance of colonization in the index case.

Of 223 households, 73 were randomized to education-only, 76 to decolonization without reminders, 74 to decolonization with reminders. There was no significant difference in time to clearance of colonization between the education-only and decolonization groups (log-rank P=.768). In secondary analyses, compliance with decolonization was associated with decreased time to clearance (P=.018).

Total household decolonization did not result in decreased time to clearance of MRSA colonization among adults and children with MRSA skin and soft-tissue infection. However, subjects who were compliant with the protocol had more rapid clearance

Trial registration. ClinicalTrials.gov identifier: NCT00966446

Infect Control Hosp Epidemiol 2016;1–8

To identify risk factors for recurrent methicillin-resistant Staphylococcus aureus (MRSA) colonization.

Prospective cohort study conducted from January 1, 2010, through December 31, 2012.

Five adult and pediatric academic medical centers.

Subjects (ie, index cases) who presented with acute community-onset MRSA skin and soft-tissue infection.

Index cases and all household members performed self-sampling for MRSA colonization every 2 weeks for 6 months. Clearance of colonization was defined as 2 consecutive sampling periods with negative surveillance cultures. Recurrent colonization was defined as any positive MRSA surveillance culture after clearance. Index cases with recurrent MRSA colonization were compared with those without recurrence on the basis of antibiotic exposure, household demographic characteristics, and presence of MRSA colonization in household members.

The study cohort comprised 195 index cases; recurrent MRSA colonization occurred in 85 (43.6%). Median time to recurrence was 53 days (interquartile range, 36–84 days). Treatment with clindamycin was associated with lower risk of recurrence (odds ratio, 0.52; 95% CI, 0.29–0.93). Higher percentage of household members younger than 18 was associated with increased risk of recurrence (odds ratio, 1.01; 95% CI, 1.00–1.02). The association between MRSA colonization in household members and recurrent colonization in index cases did not reach statistical significance in primary analyses.

A large proportion of patients initially presenting with MRSA skin and soft-tissue infection will have recurrent colonization after clearance. The reduced rate of recurrent colonization associated with clindamycin may indicate a unique role for this antibiotic in the treatment of such infection.

Infect. Control Hosp. Epidemiol. 2015;36(7):786–793

To develop and field test an implementation assessment tool for assessing progress of hospital units in implementing improvements for the prevention of ventilator-associated pneumonia (VAP) in a two-state collaborative, including data on actions implemented by participating teams and contextual factors that may influence their efforts. Using the data collected, learn how implementation actions can be improved and analyze effects of implementation progress on outcome measures.

We developed the tool as an interview protocol that included quantitative and qualitative items addressing actions on the Comprehensive Unit-based Safety Program (CUSP) and clinical interventions for use in guiding data collection via telephone interviews.

We conducted interviews with leaders of improvement teams from units participating in the two-state VAP prevention initiative.

We collected data from 43 hospital units as they implemented actions for the VAP initiative and performed descriptive analyzes of the data with comparisons across the 2 states.

Early in the VAP prevention initiative, most units had made only moderate progress overall in using many of the CUSP actions known to support their improvement processes. For contextual factors, a relatively small number of barriers were found to have important negative effects on implementation progress (in particular, barriers related to workload and time issues). We modified coaching provided to the unit teams to reinforce training in weak spots that the interviews identified.

These assessments provided important new knowledge regarding the implementation science of quality improvement projects, including feedback during implementation, and give a better understanding of which factors most affect implementation.