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.

Peripherally inserted central catheters (PICC) and midline catheters (MC) are widely used for intravenous infusions in oncology and critically ill patients. However, controversy remains regarding which method is superior. This meta-analysis systematically compares the safety differences between these 2 methods of intravenous catheterization.

Eligible studies comparing PICC and MC were identified through searches in 6 databases. Thrombosis is the primary endpoint, while secondary endpoints include other complications, cost, and satisfaction rate.

Fourteen studies with 20,675 patients were analyzed. Based on patient data, the MC group exhibited higher rates of catheter-related superficial vein thrombosis (SVT) (risk ratio [RR]: 0.42 [0.28, 0.64]), infiltrations (RR: 0.27 [0.12, 0.62]), and leaks (RR: 0.16 [0.05, 0.53]). In contrast, the PICC group had more catheter-related bloodstream infections (RR: 1.95 [1.15, 3.32]). Considering catheter days, the MC group showed increased total complications (RR: 0.51 [0.26, 0.99]), catheter-related thrombosis (deep vein thrombosis [DVT]+SVT) (RR: 0.41 [0.18, 0.95]), and leaks (RR: 0.17 [0.05, 0.64]). In the PICC group, the top 3 complications were catheter occlusions (20 per 1,000 catheter days [CDs]), pain (15 per 1,000 CDs), and phlebitis (11 per 1,000 CDs); for the MC group, they were leaks (33 per 1,000 CDs), premature removals (22 per 1,000 CDs), and catheter-related DVT (22 per 1,000 CDs). Additionally, the PICC group had higher dissatisfaction rates (RR: 4.77 [2.33, 9.77]) and increased costs.

Compared to MC, PICC appears to be a safer intravenous catheterization option for adult patients, exhibiting fewer complications. However, the higher associated costs and lower satisfaction rates of PICC warrant serious attention.

Restricting infectious healthcare workers (HCWs) from the workplace is an important infection prevention strategy. The duration of viral shedding or symptoms are often used as proxies for the infectious period in adults but may not accurately estimate it.

To determine the risk period for transmission among previously healthy adults infected with SARS-CoV-2 omicron variant (omicron) or influenza A (influenza) by examining the duration of shedding and symptoms, and day of symptom onset in secondary cases of transmission pairs.

Rapid review

This rapid review adhered to PRISMA-ScR; five databases were searched. The cumulative daily proportion of participants with an outcome of interest was calculated for each study and summarized.

Forty-three studies were included. Shedding resolved among ≥ 70% of participants by the end of day nine post symptom onset for omicron, and day seven for influenza; and for ≥ 90% of participants, by the end of day 10 for omicron and day nine for influenza. Two studies suggested shedding continues > 24 hours post-fever resolution for both viruses. Symptom onset occurred in ≥ 80% of secondary cases by the end of day seven post-primary case symptom onset for omicron and day six for influenza.

Omicron shedding is consistent with previous recommendations to exclude infected HCWs from work for 10 days; and influenza follows a similar trend. Earlier symptom onset in most secondary cases for both pathogens indicates that, despite persistent viral shedding, most transmission occurs earlier; and the cumulative serial interval might better approximate the duration of infectiousness.

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.

To determine the regional impact of transmission of multidrug-resistant organisms (MRDOs) and Clostridioides difficile (C. difficile) among a tertiary care hospital and surrounding facilities including long-term care facilities (LTCFs).

Retrospective cohort study.

Patients admitted to a tertiary care hospital from July 2019 to July 2021 were recruited if their clinically collected cultures grew the following pathogens: Methicillin-resistant Staphylococcus aureus (MRSA), Extended-Spectrum Beta-Lactamase (ESBL) producing Enterobacterales, Pseudomonas aeruginosa with difficult-to-treat resistance, Carbapenem-resistant Enterobaterales, Vancomycin-resistant Enterococci, and C. difficile. Patient characteristics including admission and discharge pathway were collected. For the isolates of MRSA, ESBL-producing Escherichia coli (E. coli), and C. difficile, a molecular epidemiological analysis was conducted, utilizing the PCR-based Open-Reading Frame Typing (POT) method.

Three hundred-five patients were identified with a total of 332 culture specimens of the target pathogens. The top three were 132 MRSA isolates (43.3%, out of 305), 97 ESBL E. coli (31.8%), and 32 ESBL Enterobacterales (non-E. coli) (10.5%). The target pathogens were more detectable within 3 days among patients admitted from LTCFs or other hospitals than those admitted from home (Odds Ratio 4.6, 95% confidence interval 2.8-7.6, p-value < 0.001). The molecular epidemiological analysis suggested the transmissions of MRSA, ESBL E. coli and C. difficile occurred 52 out of 111 patients within the in-hospital environment, and 7 out of 128 within the prehospital environment, respectively.

MDROs/C. difficile transmission is prevalent within a tertiary care hospital and further complicated by its inter-facility transmission across surrounding LTCFs and hospitals in Japan.

To evaluate the impact of a mobile-app-based central line-associated bloodstream infection (CLABSI) prevention program in nursing home residents with peripherally inserted central catheters (PICCs).

Pre-post prospective cohort study with baseline (September 2015–December 2016), phase-in (January 2017–April 2017), and intervention (May 2017–December 2018). Generalized linear mixed models compared intervention with baseline frequency of localized inflammation/infection, dressing peeling, and infection-related hospitalizations. Cox proportional hazards models compared days-to-removal of lines with localized inflammation/infection.

Six nursing homes in Orange County, California.

Adult nursing home residents with PICCs.

CLABSI prevention program consisting of an actionable scoring system for identifying insertion site infection/inflammation coupled with a mobile-app enabling photo-assessments and automated physician alerting for remote response.

We completed 8,131 assessments of 817 PICCs in 719 residents (baseline: 4,865 assessments, 422 PICCs, 385 residents; intervention: 4,264 assessments, 395 PICCs, 334 residents). The intervention was associated with 57% lower odds of peeling dressings (OR 0.43, 95% CI 0.28–0.64, P < .001), 73% lower local inflammation/infection (OR = 0.27, 95% CI: 0.13–0.56, P < .001), and 41% lower risk of infection-related hospitalizations (OR = 0.59, 95% CI: 0.42–0.83, P = .002). Physician mobile-app alerting and response enabled 62% lower risk of lines remaining in place after inflammation/infection was identified (HR 0.38, CI: 0.24–0.62, P < .001) and 95% faster removal of infected lines from mean (SD) 19 (20) to 1 (2) days.

A mobile-app-based CLABSI prevention program decreased the frequency of inflamed/infected central line insertion sites, improved dressing integrity, increased speed of removal when inflammation/infection were found, and reduced infection-related hospitalization risk.

Carbapenem-resistant Enterobacterales (CRE) are an urgent threat to healthcare, but the epidemiology of these antimicrobial-resistant organisms may be evolving in some settings since the COVID-19 pandemic. An updated analysis of hospital-acquired CRE (HA-CRE) incidence in community hospitals is needed.

We retrospectively analyzed data on HA-CRE cases and antimicrobial utilization (AU) from two community hospital networks, the Duke Infection Control Outreach Network (DICON) and the Duke Antimicrobial Stewardship Outreach Network (DASON) from January 2013 to June 2023. The zero-inflated negative binomial regression model was used owing to excess zeros.

126 HA-CRE cases from 36 hospitals were included in the longitudinal analysis. The pooled incidence of HA CRE was 0.69 per 100,000 patient days (95% confidence interval [95% CI], 0.57–0.82 HA-CRE rate significantly decreased over time before COVID-19 (rate ratio [RR], 0.94 [95% CI, 0.89–0.99]; p = 0.02), but there was a significant slope change indicating a trend increase in HA-CRE after COVID-19 (RR, 1.32 [95% CI, 1.06–1.66]; p = 0.01). In 21 hospitals participating in both DICON and DASON from January 2018 to June 2023, there was a correlation between HA-CRE rates and AU for CRE treatment (Spearman’s coefficient = 0.176; p < 0.01). Anti-CRE AU did not change over time, and there was no level or slope change after COVID.

The incidence of HA-CRE decreased before COVID-19 in a network of community hospitals in the southeastern United States, but this trend was disrupted by the COVID-19 pandemic.

Bathing intensive care unit (ICU) patients with chlorhexidine gluconate (CHG) decreases healthcare-associated infections (HAIs). The optimal method of CHG bathing remains undefined.

Prospective crossover study comparing CHG daily bathing with 2% CHG-impregnated cloths versus 4% CHG solution. In phase 1, from January 2020 through March 2020, 1 ICU utilized 2% cloths, while the other ICU utilized 4% solution. After an interruption caused by the coronavirus disease 2019 pandemic, in phase 2, from July 2020 through September 2020, the unit CHG bathing assignments were reversed. Swabs were performed 3 times weekly from patients’ arms and legs to measure skin microbial colonization and CHG concentration. Other outcomes included HAIs, adverse reactions, and skin tolerability.

411 assessments occurred after baths with 2% cloth, and 425 assessments occurred after baths with 4% solution. Average microbial colonization was 691 (interquartile range 0, 30) colony-forming units per square centimeter (CFU/cm2) for patients bathed with 2% cloths, 1,627 (0, 265) CFUs/cm2 for 4% solution, and 8,519 (10, 1130) CFUs/cm2 for patients who did not have a CHG bath (P < .001). Average CHG skin concentration (parts per million) was 1300.4 (100, 2000) for 2% cloths, 307.2 (30, 200) for 4% solution, and 32.8 (0, 20) for patients without a recorded CHG bath. Both CHG bathing methods were well tolerated. Although underpowered, no difference in HAI was noted between groups.

Either CHG bathing method resulted in a significant decrease in microbial skin colonization with a greater CHG concentration and fewer organisms associated with 2% CHG cloths.

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.

Environmental features of a patient’s room depend on the patient’s level of acuity and their clinical manifestations upon admission and during their hospital stay. In this study, we wish to apply statistical methodology to explore the association between room features and hospital onset infections caused by Clostridioides difficile (HO-CDI) while accounting for room assignment.

We conducted a nested case–control study using retrospective electronic health record (EHR) data of patients hospitalized at the Ohio State University Wexner Medical Center (OSUWMC) between January 2019 and April 2021. We collected clinical information and combined that with room-based information, collected as surveys. Data were analyzed to assess the association between room factors and HO-CDI.

2427 patients and 968 unique rooms were included in the study. Results indicated protective effects for rooms with cubical curtains near the patient (OR = 0.705, 95% CI = 0.549–0.906), rooms with separate shower units (OR = 0.674, 95% CI = 0.528–0.860), rooms with wall-mounted toilets (OR = 0.749, 95% CI = 0.592–0.950), rooms with sliding bathroom doors (OR = 0.593, 95% CI = 0.432–0.816), and sliding door knobs (OR = 0.593, 95% CI = 0.431-0.815). Rooms with manual paper towel dispensers had increased odds of HO-CDI (OR = 1.334, 95% CI = 1.053–1.691) compared to those with automatic towel dispensers.

Results suggest possible association between specific room features and HO-CDI, which could be further investigated with techniques like environmental sampling. Moreover, findings from the study offer valuable insights for targeted intervention measures.

Post-procedural antimicrobial prophylaxis is not recommended by professional guidelines but is commonly prescribed. We sought to reduce use of post-procedural antimicrobials after common endoscopic urologic procedures.

A before-after, quasi-experimental trial with a baseline (July 2020–June 2022), an implementation (July 2022), and an intervention period (August 2022–July 2023).

Three participating medical centers.

We assessed the effect of a bundled intervention on excess post-procedural antimicrobial use (ie, antimicrobial use on post-procedural day 1) after three types of endoscopic urologic procedures: ureteroscopy and transurethral resection of bladder tumor or prostate. The intervention consisted of education, local champion(s), and audit-and-feedback of data on the frequency of post-procedural antimicrobial-prescribing.

1,272 procedures were performed across all 3 sites at baseline compared to 525 during the intervention period; 644 (50.6%) patients received excess post-procedural antimicrobials during the baseline period compared to 216 (41.1%) during the intervention period. There was no change in the use of post-procedural antimicrobials at sites 1 and 2 between the baseline and intervention periods. At site 3, the odds of prescribing a post-procedural antimicrobial significantly decreased during the intervention period relative to the baseline time trend (0.09; 95% CI 0.02–0.45). There was no significant increase in post-procedural unplanned visits at any of the sites.

Implementation of a bundled intervention was associated with reduced post-procedural antimicrobial use at one of three sites, with no increase in complications. These findings demonstrate both the safety and challenge of guideline implementation for optimal perioperative antimicrobial prophylaxis.

This trial was registered on clinicaltrials.gov, NCT04196777.

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.

Patients with chronic kidney disease suffer from immune dysfunction, increasing susceptibility to infections. The aim of the study was to investigate air contamination with respiratory viruses in a dialysis unit at a quaternary hospital using molecular detection techniques and to analyze airflow dynamics through computational fluid dynamics (CFD) simulations for a comprehensive assessment of air transmission risks.

We conducted dialysis unit air sampling using AerosolSense™ samplers. Air and clinical sampling occurred during three periods in 2022: winter, early, and late fall. A technical team maintained the dialysis unit’s ventilation system during mid fall. Ventilation system capacity and airflow rates were measured. CFD simulations were used to evaluate airflow dynamics.

The investigation collected 144 air samples, revealing heterogeneous virus detection rates across locations and study periods. Virus positivity correlated with the presence of patients and the effectiveness of the ventilation system. The ratio of virus air positivity to virus patient positivity was 1.84 and 3.35 during the first and the second periods, respectively, and collapsed to 0.64 after maintenance. Airflow rate measurements highlighted a ninefold discrepancy between actual and theoretical airflow (393 m3/h vs. 3530 m3/h), which was rectified by maintenance actions. Airflow dynamics and particle dispersion visualization through CFD simulations contributed to a better understanding of transmission risks.

Detection of viruses in the air, combined with CFD, revealed deficiencies in air renewal. Maintenance interventions significantly improved airflow dynamics and particle dispersion, reducing airborne virus spread.