Contact Isolation Precautions Research Articles

Analysis of transmission-related third-generation cephalosporin-resistant Enterobacterales by electronic data mining and core genome multi-locus sequence typing

To contain intra-hospital transmission of third-generation cephalosporin-resistant Enterobacterales (3GCR-E), contact isolation precautions are recommended. To quantify transmissions of 3GCR Escherichia coli and 3GCR Klebsiella pneumoniae within a hospital. An automated outbreak detection system (AODS) was used to identify clusters (N≥2) of 3GCR Enterobacterales for the years 2016, 2018 and 2020. Clusters were defined by phenotypic agreement of microbiological results and spatial and temporal relationship. Core genome multi-locus sequence typing (cgMLST) was used to confirm whether the cluster isolates were transmitted between patients. A total of 4343 3GCR E.coli and 1377 K.pneumoniae isolates were analysed. Among the 3GCR E.coli isolates, the AODS identified 304 isolates as cluster isolates, the median cluster size was two (range: 2-5). The cgMLST analysis revealed that a total of 23 (7.5%) 3GCR E.coli cluster isolates were transmission-associated, of which 20 isolates (87%) were detected in intensive care patients. Among the 3GCR K.pneumoniae isolates, the AODS identified 73 isolates as cluster isolates, the median cluster size was two (range: 2-4). CgMLST revealed that 35 (48%) 3GCR K.pneumoniae cluster isolates were transmission associated, of which 27 isolates (77%) were detected in intensive care patients. For 3GCR K.pneumoniae, cgMLST confirmed the AODS results more frequently than for 3GCR E.coli. Therefore, contact isolation precautions for 3GCR K.pneumoniae may be appropriate on intensive care units, but only in certain circumstances, such as outbreaks, for Enterobacterales with lower transmissibility, such as E. coli.

Active surveillance for carbapenem resistant enterobacteriaceae (CRE) using stool cultures as a method to decrease CRE infections in the pediatric intensive care unit (PICU)

BackgroundThe incidence of Carbapenem Resistant Enterobacteriaceae (CRE) infections is increasing worldwide. Due to dearth of alternative antibiotics, prevention of infection transmission is a part of CRE infection management strategy. Early detection of CRE by active surveillance coupled with contact isolation is much more appropriate compared to contact isolation upon receipt of routine cultures dictated by the patient's clinical condition. ObjectivesTo determine whether active CRE surveillance will decrease CRE infection rates in the Pediatric Intensive Care Unit (PICU). MethodsRetrospective observational study done in the 10-bed PICU of a tertiary care teaching children's hospital from July 2013 to June 2015. Rectal swabs for CRE were sent from all PICU patients except stable post-operative patients. Contact isolation precautions were followed for rectal swab positive patients. CRE colonization and infection rates were calculated and compared. ResultsTotal of 1262 rectal swabs were sent from 1022 patients. CRE colonization rate was 19.5%. Post intervention, ICU acquired CRE colonization decreased by 36% and ICU acquired CRE infection rates decreased by 100%, both showed significant decrease (p ​< ​0.0001). ConclusionActive CRE surveillance and institution of contact isolation in appropriate situations is helpful in decreasing CRE colonization and infection rates in the PICU.

Synergy between infection control and antimicrobial stewardship programs to control carbapenem-resistant Enterobacterales.

Argentina is the third country in the world with the higher levels of CRE. The primary objective is to achieve an optimal result in the CRE infection rate after the implementation of an IPC program and antimicrobial stewardship programs (ASP) in a large teaching hospital in Argentina. Retrospective, observational study from January 2018 to December 2021, in a 220-bed tertiary care teaching hospital in Buenos Aires province. Actions aimed at CRE control and prevention included CRE and healthcare-associated infection (HAI) surveillance; compliance with hand hygiene, hospital hygiene, contact isolation precautions, and care bundles for the prevention of device-associated infections; optimization of antimicrobial treatments, antimicrobial consumption, education, and feedback. Synergy between an ICP and ASP achieved controlled rate of CRE infections reaching the lowest levels during 2020 (0.08 episodes/1000 patient days). Colonization rate remained stable throughout the study period. Ventilator-associated pneumonia (VAP) rate showed a trend toward lower rates. Compliance with care bundles showed rates >85%. Antimicrobial consumption increased slightly during the study period (15%). Among high-impact antimicrobials, only colistin consumption increased. Our study demonstrates the sustained and beneficial impact of an IPC Program and an ASP to control CRE infection.

Screening for carriers of carbapenemase producing Enterobacteriaceae in critical care units

Background: The increasing cases of carbapenemase resistant Enterobacteriaceae (CRE) across the world is a cause of concern. Asymptomatic carriage of CRE in critical care units is a menace to infection control. Aims: This study determines the carriage rate of CRE in patients admitted to the intensive care units (ICU's) and evaluates the potential risk factors, leading to colonization in patients with CRE. Materials and Methods: Sixty rectal swabs from patients in the ICU's were screened for carriage of CRE. The samples were inoculated onto ChromID CARBA SMART bi-plate. The organisms showing color appearances as per the manufacturer's instructions were considered as CRE. Routine disk diffusion technique was also employed and CRE was defined as an organism belonging to the Enterobacteriaceae family which was resistant to either imipenem or meropenem. Results: The organisms isolated were identified and the percentage of carriage of carbapenem-resistant organisms was 12 (20%), of which Klebsiella pneumoniae was 4 (33.3%), Escherichia coli 6 (50%), Citrobacter freundii 1 (8.3%), and Enterobacter spp. 1 (8.3%). Out of these, 2 (3.3%) showed OXA 48 type resistance seen with K. pneumoniae and E. coli. Prior hospitalization, the use of high-end antibiotics and patients who have undergone surgeries were the most common potential risk factors for colonization with CRE. Conclusion: The prompt detection of CRE by routine screening using cost-effective methods and reduction of potential risk factors for gut colonization reduce the transmission of drug resistance in any hospital setting and pave the way for better antibiotic stewardship and appropriate contact isolation precautions.

European survey on the current surveillance practices, management guidelines, treatment pathways and heterogeneity of testing of Clostridioides difficile, 2018–2019: results from The Combatting Bacterial Resistance in Europe CDI (COMBACTE-CDI)

Awareness and compliance with international guidelines for diagnosis and clinical management of Clostridioides difficile infection (CDI) are unknown. To compare the awareness and compliance with the recommended strategies for diagnosis and clinical management of CDI across Europe in 2018-2019. Hospital sites and their associated community practices across 12 European countries completed an online survey in 2018-2019, to report on their practices in terms of surveillance, prevention, diagnosis, and treatment of CDI. Responses were collected from 105 hospitals and 39 community general practitioners (GPs). Hospital sites of 11 countries reported participation in national surveillance schemes compared with six countries for international schemes. The European Society of Clinical Microbiology and Infectious Diseases (ESCMID)-recommended CDI testing methodologies were used by 82% (86/105) of hospitals, however countries reporting the highest incidence of CDI used non-recommended tests. Over 75% (80/105) of hospitals were aware of the most recent European CDI treatment guidelines at the time of this survey compared with only 26% (10/39) of surveyed GPs. However, up to 15% (16/105) of hospitals reported using the non-recommended metronidazole for recurrent CDI cases, sites in countries with lower awareness of CDI treatment guidelines. Only 37% (39/105) of hospitals adopted contact isolation precautions in case of suspected CDI. Good awareness of guidelines for the management of CDI was observed across the surveyed European hospital sites. However, low compliance with diagnostic testing guidelines, infection control measures for suspected CDI, and insufficient awareness of treatment guidelines continued to be reported in some countries.

Monkeypox: Past to Present

Poxviridae ailesine ait zoonotik bir hastalık olan maymun çiçeği 1958 yılında maymunlardan izole edilmiştir. İnsanlarda çiçek hastalığına benzer bir klinik oluşturur. Enfekte hayvan ısırığı, vücut sıvıları ile temas ve damlacık yoluyla bulaş tipiktir. 2003 ve sonrasında özellikle ithalat ve turizm nedenli seyahat ile birçok ülkede salgınlara neden olmuştur. 2022 yılında görülen salgında ise bulaşın cinsel aktivite ile ilişkili olduğu düşünülmektedir. Çiçek aşısı ile bağışıklanmamış bireyler hastalık açısından risk grubunu oluşturmaktadır. İnkübasyon süresinin ortalama 6-13 gün olduğu kabul edilir. Ateş, lenfadenopati ve miyalji varlığı diğer döküntülü hastalıklardan ayırt edicidir. Ayırıcı tanıda numunelerin referans laboratuvara gönderilerek doğrulamasının yapılması şarttır. Şüphelenilen vakalar hakkında yerel halk sağlığı yetkililerine bilgi verilmesi gerekir. Destek tedavisi esastır. Özel hasta grupları için tekovirimat, brinsidofovir veya sidofovir gibi antiviral tedaviler halk sağlığı yetkilileri onayı ile başlanabilir. Ayırıcı tanı olarak düşünüldüğü her durumda tanı dışlanana kadar temas, damlacık ve solunum izolasyon önlemleri de uygulanmalıdır. Temas öncesi veya temas sonrası profilaksi için yine yerel halk sağlığı yetkilileri onayı ile çiçek aşısı uygulanabilir.

A hospital-wide outbreak of IMI-17-producing Enterobacter ludwigii in an Israeli hospital

AbsractBackgroundTo describe the course and intervention of an hospital-wide IMI-Producing Enterobacter ludwigii outbreak.MethodsThis was an outbreak interventional study, done at a tertiary care center in Tel-Aviv, Israel. Data was collected on the course of the outbreak and the demographic and clinical characteristics of all patients involved in the outbreak. The intervention measures included patients’ cohorting, contact isolation precautions, environmental cleaning and screening of contacts. The molecular features and phylogeny of outbreak-related isolates were studied by whole-genome based analysis.ResultsThe outbreak included 34 patients that were colonized by IMI-Producing E. ludwigii and were identified in 24 wards throughout the hospital. Colonization was identified in the first 72 h of admission in 13/34 patients (38.2%). Most patients (91.2%) were admitted from home and had relatively low level of comorbidities. The majority of them (88%) had no recent use of invasive catheters and none had previous carriage of other multi-drug resistant bacteria. All available isolates harbored the blaIMI-17 allele and belonged to Sequence-Type 385. With the exception of two isolates, all isolates were closely related with less than a 20-SNP difference between them.ConclusionsThis outbreak had most likely originated in the community and subsequently disseminated inside our institution. More studies are required in order to elucidate the epidemiology of IMI-Producing E. ludwigii and the possible role of environmental sources in its dissemination.

International Multicentre Study of Candida auris Infections.

Background:Candida auris has emerged globally as a multi-drug resistant yeast and is commonly associated with nosocomial outbreaks in ICUs. Methods: We conducted a retrospective observational multicentre study to determine the epidemiology of C. auris infections, its management strategies, patient outcomes, and infection prevention and control practices across 10 centres from five countries. Results: Significant risk factors for C. auris infection include the age group of 61–70 years (39%), recent history of ICU admission (63%), diabetes (63%), renal failure (52%), presence of CVC (91%) and previous history of antibiotic treatment (96%). C. auris was commonly isolated from blood (76%). Echinocandins were the most sensitive drugs. Most common antifungals used for treatment were caspofungin (40%), anidulafungin (28%) and micafungin (15%). The median duration of treatment was 20 days. Source removal was conductedin 74% patients. All-cause crude mortality rate after 30 days was 37%. Antifungal therapy was associated with a reduction in mortality (OR:0.27) and so was source removal (OR:0.74). Contact isolation precautions were followed in 87% patients. Conclusions: C. auris infection carries a high risk for associated mortality. The organism is mainly resistant to most azoles and even amphotericin-B. Targeted antifungal therapy, mainly an echinocandin, and source control are the prominent therapeutic approaches.

Impact of Two-Step Testing Algorithm on Reducing Hospital-Onset Clostridioides difficile Infections

Clostridioides difficile infection (CDI) is one of the leading causes of hospital–onset infections. Clinically distinguishing true CDI versus colonization with C. difficile is challenging and often requires reliable and rapid molecular testing methods. At our academic center, we implemented a 2-step testing algorithm to help identify true CDI cases. The University of Mississippi Medical Center is a 700+ bed academic facility located in Jackson, Mississippi. Hospital-onset (HO) CDI was defined based on NHSN Laboratory Identified (LabID) event as the last positive C. difficile test result performed on a specimen using a multistep testing algorithm collected &gt;3 calendar days after admission to the facility. HO-CDI data were collected from all inpatient units except the NICU and newborn nursery. HO-CDI outcomes were assessed based on standardized infection ratio (SIR) data. In May 2020, we implemented a 2-step testing algorithm (Figure 1). All patients with diarrhea underwent C. difficile PCR testing. Those with positive C. difficile PCR test were reflexed to undergo enzyme immunoassay (EIA) glutamate dehydrogenase antigen (Ag) testing and toxin A and B testing. The final results were reported as colonization (C. difficile PCR+/EIA Ag+/Toxin A/B−) or true CDI case (C. difficile PCR+/EIA +/Toxin A/B +) or negative (C. difficile PCR−). All patients with colonization or true infection were placed under contact isolation precautions until diarrhea resolution for 48 hours. During the preintervention period (October 2019–April 2020), 25 HO-CDI cases were reported compared to 8 cases in the postintervention period (June 2020–December 2020). A reduction in CDI SIR occurred in the postintervention period (Q3 2020–Q4 2020, SIR 0.265) compared to preintervention period (Q4 2019–Q1 2020, SIR 0.338) (Figure 2). We successfully reduced our NHSN HO-CDI SIR below the national average after implementing a 2-step testing algorithm for CDI. The 2-step testing algorithm was useful for antimicrobial stewardship to guide appropriate CDI treatment for true cases and for infection prevention to continue isolation of infected and colonized cases to reduce the spread of C. difficile spores.Funding: NoDisclosures: None

Investigation of the First Case of New Delhi Metallo-β-Lactamase-1–Producing Pseudomonas aeruginosa in Texas

Background: New Delhi metallo-β-lactamases impart resistance to carbapenems. Enterobacteriaceae carrying New Delhi metallo-β-lactamases have been reported before. However, only 7 cases of blaNDM-carrying Pseudomonas aeruginosa has been reported from 4 states in the United States as of January 1, 2018, according to the CDC. We describe an epidemiologic investigation of the first reported case of blaNDM-carrying Pseudomonas aeruginosa in Texas and the measures that controlled the spread of the organisms carrying this gene at a 30-bed spinal cord injury unit (SCI) and the acute-care hospital within the Veterans’ Affairs North Texas Health Care System. Methods: After identification of blaNDM-1–carrying P. aeruginosa from a urine culture in an SCI patient who received medical treatment in Thailand prior to transfer, we performed a rectal screen for the presence of blaNDM in the index patient’s hospital roommates. Based on the results, we expanded the investigation to other patient care units that had provided care to the patient. We initiated universal contact isolation precautions, 1:1 nursing care, restricted movement, phased point-prevalence testing, and intense environmental cleaning until the threat of blaNDM was mitigated. Whole-genome sequencing (WGS) was performed on clinical isolates from the index patient and the roommates by the CDC. Results: Of the 2 roommates of the index, 1 patient had a urine culture positive for blaNDM-5-carrying Escherichia coli. The second roommate has subsequently grown blaNDM-1-carrying P. aeruginosa from a clinical culture. A third patient who was in the same unit as the index patient but not in the same room in an acute-care unit tested positive for blaNDM in a rectal screen. Of the 54 patients who were hospitalized in the same unit as the index patient, 26 refused to get the test and 28 tested negative. In addition, point-prevalence rectal screening was conducted in the SCI in 3 phases that were 3 to 4 weeks apart. All of these screening tests were negative. WGS revealed that the index patient and roommate 2 had blaNDM-1–carrying P. aeruginosa, whereas the roommate 1 had blaNDM-5–carrying E. coli. No further spread occurred. Conclusions: Our aggressive efforts quickly mitigated further spread of blaNDM. Our epidemiologic investigation indicates that an intergenus transfer of blaNDM from P. aeruginosa to E. coli likely took place. In addition, it appears there was an evolution of NDM-1 to NDM-5, which differs from the former by 2 amino acid substitutions at positions 88 (Val→Leu) and 154 (Met→Leu). This type of evolution has been shown by prior studies to confer increased antibiotic resistance in certain resource limited settings.Funding: NoneDisclosures: None

Isolation protocol for a COVID-2019 patient requiring emergent surgical intervention: case presentation

BackgroundThe concerns of the highly contagious and morbid nature of Coronavirus Disease-2019 (COVID-2019) have prompted healthcare workers to implement strict droplet and contact isolation precautions. Unfortunately, some patients who may be or presumptively or confirmed as infected with COVID-2019 may also require emergent surgical procedures. As such, given the high-risk for exposure of many healthcare workers involved the complex requirements for appropriate isolation must be adhered to.Case presentationWe present our experience with a 77-year-old who required emergency cardiac surgery for a presumed acute aortic syndrome in the setting of a presumed, and eventually confirmed, COVID-2019 infection. We outline the necessary steps to maintain strict isolation precautions to limit potential exposure to the surgical Team.ConclusionsWe hereby provide our algorithm for emergent surgical procedures in critically-ill patients with presumptive or confirmed infection with COVID-2019. The insights from this case report can potentially be templated to other facilities in order to uphold high standards of infection prevention and patient safety in surgery during the current COVID-19 pandemic.

1196. Is the Weekend Staff Really to Blame? Challenges in Isolation Compliance at an Academic Tertiary Care Center

BackgroundTransmission-based isolation precautions are implemented in an effort to decrease the risk of transmission of pathogens. Weekend staff are perceived to have lower compliance.MethodsVisual observation of healthcare worker (HCW) compliance with an institutional isolation precautions practices was done at an academic tertiary care center. In the first quarter of 2019, observations were completed for 894 patients who required contact, droplet or airborne isolation precautions. Observations included patients with infection or colonization with multi-drug-resistant organisms (MDRO) or highly transmissible infections. Observations focused on availability of appropriate supplies, compliance with infection control practices, and documentation. Audits were performed on workdays and weekends, and results were communicated to unit leadership via email. Comparison of proportions was calculated using the normal approximation in Minitab18.ResultsCompliance with the different elements of the audit can be seen in Table 1. HCW compliance with the use of personal protective equipment and hand hygiene on exit from the room had the lowest compliance and was statistically lower on weekends than on weekdays, and compliance was significantly lower than all other categories for both weekday and weekend measurements. Fifty-seven percent of all patients had missed compliance on one or more elements. There was not a statistically significant variation in practice between weekends and weekdays in overall compliance.ConclusionThere is opportunity for improvement in all compliance on isolation practices facility-wide, and elements that require changes in behavior had the lowest compliance, and were lower on weekend shifts. We did not find other differences in performance for weekend staff vs. weekday staff. Educational measures should focus on all individual staff across all shifts. Disclosures All authors: No reported disclosures.

Children's and parents' views on hospital contact isolation: A qualitative study to highlight children's perspectives.

To date, there has been a paucity of studies conducted on the experiences of children under hospital contact isolation precautions. Furthermore, the studies that have examined children's experiences at the hospital typically reflect the perspectives of their parents, and few have directly involved interviews with children themselves, and even fewer with children in isolation. To address this gap, we conducted semi-structured, open-ended interviews with hospitalized children to assess their experiences of being placed in isolation. Where possible, the children's parents also completed written surveys to assess parental perspectives on their child's experiences. Two important findings of the study were the children's resilience during a difficult time and children's varying awareness of the pathophysiology of infections as it relates to isolation precautions. Examination of the parent-child dyads elucidated some discordance between parents' and children's perspectives on how children experienced their isolation, on what the children's preferred activities were while in isolation, and how much children understood about the reasons they were in isolation. This study supports earlier studies that suggest that the benefits of isolation procedures may be outweighed by how negatively isolation is experienced by patients, particularly when the patients are children. It also highlights the need for child-friendly isolation signs. Because parental and child perceptions differed in cases where data from both were available, this study suggests larger studies on children's perspectives and/or on parent-child dyads are needed.

462. “All Eyes on You”: A Covert Observational Study on Contact Precaution Compliance in Six Hospitals at the Detroit Medical Center

BackgroundThe Center for Disease Control and Prevention recommends strict contact isolation precautions (CP) that include hand hygiene (HH) and barrier (gloves and gown) precautions upon entering and leaving the rooms of patients diagnosed with multidrug-resistant organism or Clostridium difficile infections. Although this policy has been in place for several years, compliance rate among HCW is rarely studied. The aim of our study was to covertly monitor, analyze, and compare the overall bundle compliance (OBC) and individual (HH, glove and gown) component compliance (ICC) among HCWs during routine patient care.MethodsA prospective observational study was done in six Detroit Medical Centers (July 2017 to February 2018). Trained observers audited both inpatient and intensive care units on random days and time. Components audited (1) HH before donning and after doffing (2) gowning and gloving techniques before entering and after existing the patient room. A mobile application (speedy audit) was used to record all data. A pilot targeted education program (TEP) was also conducted in one of the hospitals where education was focused only on strict HH practice before donning.ResultsA total of 6,274 observations were collected. The OBC was 38%. Common HCWs observed included nurses (registered nurse and nursing student) 47%; physicians (attending’s, residents, fellows) 28%; service workers including Environmental Service, Food service, Patient transporter, Social worker, Pastoral care- 14%; Allied Health Professions including Dietician, Blood Collection, Physiotherapist, Radiology Tech, Respiratory Therapist 4%; The OBC among all HCW were below 50%. For the ICC, HH (49%) was way below the gloving (80%,) and gowning (62%) compliance. HH compliance before donning was strikingly lower (40%) than the compliance after doffing (62%). This trend was similar in all HCW. Within a month of TEP, a drastic increase in both HH [↑ to 75% from 26% (P < 0.001)] and OBC [↑ to 68% from 16% (P < 0.001)] was seen.ConclusionCommon misconception that gloves are substitute to HH could explain the low HH rates before donning. Recognition of this gap and focused education on HH before donning has led to improved compliance in all HCW.Disclosures All authors: No reported disclosures.

Epidemiology of carbapenemase-producing Enterobacteriaceae in a pediatric hospital in a country with high endemicity

BackgroundLittle is known about epidemiology of carbapenemase-producing Enterobacteriaceae (CPE) in children. Aim of this study was to describe CPE epidemiology in a tertiary care pediatric hospital in Italy that admits patients coming from geographic areas with high diffusion of CPE. MethodsProspective evaluation of the proportion and rates per 100,000 hospital discharges (D) or hospitalization-days (HD) of invasive infections due to CPE from 2013 to 2017 and of CPE infections and colonizations from 2014 to 2017. Disease-preventing strategies comprised patients’ screening at admission, pre-emptive contact isolation precautions pending cultures results, and bundles for prevention of healthcare associated infections. ResultsFrom 2013 to 2017 CPE represented 3.5% of all invasive infections due to Enterobacteriaceae, with rates ranging 7.30–14.33 for D and 1.03–2.06 for HD, without major changes over time. On the contrary, overall rates of isolates increased from 83.03 to 191.34 for D and from 12.21 to 28.35 for HD. The intra-hospital diffusion consisted of 2 small outbreaks without invasive diseases in 2014–2015, and sporadic, not epidemiologically-related cases in 2016–2017. Globally, Escherichia coli and Klebsiella pneumoniae represented 64% of identified CPE, while 70% of carbapenemases identified were metallo-beta-lactamases (VIM or NDM), with changes over time. ConclusionsIn our center metallo-beta lactamases were the most frequently identified carbapenemases in Enterobacteriaceae and E. coli and K. pneumoniae the most frequently isolated pathogens carrying these enzymes. A proactive management strategy was effective in containing in-hospital spreading.

Emergence of multidrug-resistant Providencia rettgeri isolates co-producing NDM-1 carbapenemase and PER-1 extended-spectrum \u03b2-lactamase causing a first outbreak in Korea

BackgroundNosocomial outbreak due to carbapenem-resistant Enterobacteriaceae has become serious challenge to patient treatment and infection control. We describe an outbreak due to a multidrug-resistant Providencia rettgeri from January 2016 to January 2017 at a University Hospital in Seoul, Korea.MethodsA total of eight non-duplicate P. rettgeri isolates were discovered from urine samples from eight patients having a urinary catheter and admitted in a surgical intensive care unit. The β-lactamase genes were identified using polymerase chain reaction and direct sequencing, and strain typing was done with pulsed-field gel electrophoresis (PFGE).ResultsAll isolates showed high-level resistance to extended-spectrum cephalosporins, aztreonam, meropenem, ertapenem, ciprofloxacin, and amikacin. They harbored the blaNDM-1 carbapenemase and the blaPER-1 type extended-spectrum β-lactamases genes. PFGE revealed that all isolates from eight patients were closely related strains.ConclusionsThe 13-month outbreak ended following reinforcement of infection control measures, including contact isolation precautions and environmental disinfection. This is the first report of an outbreak of a P. rettgeri clinical isolates co-producing NDM-1 and PER-1 β-lactamase.

A qualitative, interprofessional analysis of barriers to and facilitators of implementation of the Department of Veterans Affairs' Clostridium difficile prevention bundle using a human factors engineering approach

Clostridium difficile infection (CDI) is increasingly prevalent, severe, and costly. Adherence to infection prevention practices remains suboptimal. More effective strategies to implement guidelines and evidence are needed. Interprofessional focus groups consisting of physicians, resident physicians, nurses, and health technicians were conducted for a quality improvement project evaluating adherence to the Department of Veterans Affairs' (VA) nationally mandated C difficile prevention bundle. Qualitative analysis with a visual matrix display identified barrier and facilitator themes guided by the Systems Engineering Initiative for Patient Safety model, a human factors engineering approach. Several themes, encompassing both barriers and facilitators to bundle adherence, emerged. Rapid turnaround time of C difficile polymerase chain reaction testing was a facilitator of timely diagnosis. Too few, poorly located, and cluttered sinks were barriers to appropriate hand hygiene. Patient care workload and the time-consuming process of contact isolation precautions were also barriers to adherence. Multiple work system components serve as barriers to and facilitators of adherence to the VA CDI prevention bundle among an interprofessional group of health care workers. Organizational factors appear to significantly influence bundle adherence. Interprofessional perspectives are needed to identify barriers to and facilitators of bundle implementation, which is a necessary first step to address adherence to bundled infection prevention practices.

Respiratory Syncytial Virus Infection Control Challenges with a Novel Polymerase Chain Reaction Assay in a Tertiary Medical Center.

OBJECTIVES To evaluate host characteristics, mode of infection acquisition, and infection control procedures in patients with a positive respiratory syncytial virus (RSV) test result after the introduction of the GenXpert Influenza/RSV polymerase chain reaction (PCR) assay. DESIGN Retrospective cohort study. PATIENTS Adults with a positive PCR test result for RSV who were hospitalized in a tertiary academic medical center between January 2015 and December 2016 were included in this study. Our infection control policy applies contact isolation precautions only for immunocompromised patients. METHODS Patients were identified through 2 databases, 1 consisting of patients isolated because of RSV infection and 1 with automatically collected laboratory results. Baseline and clinical characteristics were collected through a retrospective medical chart review. The rate of and clinical factors associated with healthcare-associated RSV infections were evaluated. RESULTS In total, 108 episodes in 106 patients hospitalized with a positive Xpert RSV test result were recorded during the study period. Among them, 11 episodes were healthcare-associated infections (HAIs) and 97 were community-acquired infections (CAIs). The mean length of hospital stay (LOS, 40.2 vs 11.2 days), the mean number of room switches (3.5 vs 1.7) and ward switches (1.5 vs 0.4), and the mean numbers of contact patients (9.9 vs 3.8) were significantly longer and higher in the HAI group than in the CAI group (P<.0001). Surveillance of microbiology records and clinical data did not reveal evidence for a cluster or an epidemic during the 2-year observation period. CONCLUSIONS The introduction of a rapid molecular diagnostic test systematically applied to patients with influenza-like illness may challenge current infection control policies. In our study, patients with HAIs had a prolonged hospital stay and a high number of contact patients, and they switched rooms and wards frequently. Infect Control Hosp Epidemiol 2017;38:1291-1297.

Preoperative Staphylococcus Aureus Screening and Targeted Decolonization in Cardiac Surgery

We assessed the impact of preoperative Staphylococcus aureus screening and targeted decolonization on the incidence of postoperative methicillin-resistant S aureus (MRSA) colonization, intensive care unit MRSA transmission, and surgical site infections in cardiac surgery patients. We reviewed medical records for all adult patients during two periods: preintervention (January 2007 to April 2010) and intervention (January 2011 to December 2014). In the intervention period, we performed nasal screening for methicillin-sensitive S aureus and MRSA using polymerase chain reaction within 30 days of the operation. Colonized patients received intranasal mupirocin twice daily and chlorhexidine baths daily for 5 days; patients colonized with MRSA also received prophylactic vancomycin plus cefazolin with contact isolation precautions. Nasal surveillance for MRSA was performed on intensive care unit admission and weekly thereafter. Multivariable logistic regression models were constructed to determine risk factors for postoperative MRSA colonization, and surgical site infections and the impact of our screening program was assessed in these models. Poisson regression was used to assess MRSA transmission. Comparing 2,826 preintervention and 4,038 intervention patients, cases differed in age, diabetes mellitus, preoperative infection, preoperative length of stay, and bypass time (all p ≤ 0.03). Intervention patients had risk-adjusted reductions in MRSA colonization (odds ratio 0.53, 95% confidence interval [CI]: 0.37 to 0.76, p < 0.001), transmission (incidence rate ratio 0.29, 95% CI: 0.13 to 0.65, p= 0.002), and surgical site infections (odds ratio 0.58, 95% CI: 0.40 to 0.86, p= 0.007). Increased duration of preoperative decolonization therapy was associated with decreased postoperative MRSA colonization (odds ratio 0.73, 95% CI: 0.53 to 1.00, p= 0.05). Preoperative S aureus screening with targeted decolonization was associated with reduced MRSA colonization, transmission, and surgical site infections. Duration of preoperative therapy correlated with decreased frequency of postoperative MRSA colonization.

Contact Isolation Precautions in Trauma Patients: An Analysis of Infectious Complications.

Victims of traumatic injuries represent a population at risk for a wide variety of complications. Contact isolation (CI) is a set of restrictions designed to help prevent the transmission of medically significant organisms in the healthcare setting. A growing body of literature demonstrates that CI can have significant implications for the individual isolated patient. Our goal was to characterize the use of contact isolation at our Level I trauma center and investigate the association of CI with infectious complications. An existing trauma database containing data on patients admitted at our Level I trauma center between January 1, 2011 and December 31, 2012, along with their contact isolation status, was queried. Demographics, injuries, and the presence of infections were collected. Diagnosis of pneumonia or UTI was based on clinical documentation in the patient's medical record. A chart review was performed to ascertain the reason for CI including specific organisms. Because of differences in patient demographics between the CI and non-CI groups, linear regression was performed to adjust for the effects of different variables. A total of 4,423 patients were admitted over this period. Of these, 4,318 (97.6%) had complete records and were included in the subsequent analysis. The CI was in place in 249 (5.8%) patients; 4,069 (94.2%) were not isolated. The number who had CI initiated for MRSA nasal colonization was 173 (69.5%). Twenty-two (8.9%) had no reason for CI documented. Pneumonia occurred in 190 (4.4%), 54 (21.7) in the CI group versus 136 (3.3%) in the non-CI group. Urinary tract infection (UTI) was diagnosed in 166 (3.8%), 48 (19.3%) in the CI group versus 118 (2.9%) in the non-CI group. Using logistic regression and excluding patients placed on contact isolation for the development of a new resistant nosocomial infection, CI, Injury Severity Score, gender, length of stay, and mechanical ventilation were identified as common covariates for pneumonia (PNA) and UTI. Chronic obstructive pulmonary disease COPD was specifically identified for PNA. Spinal cord injury, vertebral column injury and pelvic-urogenital injury were also significant for UTI. The development of pneumonia and UTI in patients with trauma was significantly associated with the use of CI. Because the majority of these patients had CI precautions in place for asymptomatic colonization, the CI provided them no direct benefit. Because the use of CI is associated with multiple negative outcomes, its use in the trauma population needs to be carefully re-evaluated.