Healthcare-associated Research Articles

Dental Caries in Medicaid-Insured Preschool Children With or Without Special Health Care Needs in Northeast Ohio

Children with special health care needs (CSHCN) are recognized to be at increased risk of developing dental caries (decay). Evidence is mixed regarding the association of preventive oral health care delivered by pediatric primary care clinicians with caries experience among CSHCN. To investigate caries experience, including untreated decay, among Medicaid-enrolled preschoolers with or without special health care needs. This cross-sectional study used baseline data from the Pediatric Providers Against Cavities in Children's Teeth study, a cluster-randomized hybrid effectiveness-implementation trial conducted among 1022 Medicaid-enrolled preschoolers aged 3 to 6 years attending well-child visits at 18 participating community pediatric primary care practices in northeast Ohio. Baseline data were collected from November 1, 2017, to August 31, 2019, with statistical analyses conducted from April to August 2022. Presence of special health care needs, as assessed by applying the Pediatric Medical Complexity Algorithm to International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes, was abstracted from electronic medical records. CSHCN were defined as having either noncomplex chronic disease (presence of only 1 nonprogressive chronic condition, or multiple nonprogressive chronic conditions in a single body system) or complex chronic disease (presence of any progressive chronic condition, malignant neoplasm, or significant chronic conditions involving multiple body systems). Untreated dental decay and caries experience as assessed through clinical dental examinations using International Caries Detection and Assessment System criteria. A total of 1022 children aged 3 to 6 years from 18 practices were enrolled in the study. The mean (SD) age of the study population was 4.3 (1.1) years, 554 (54.2%) were boys, and of 988 with data on race and ethnicity, 451 (45.6%) were Black. Of these, 301 of 1019 (29.5%) had a likely special health care need (225 with noncomplex chronic conditions and 76 with complex chronic conditions). The most frequent chronic conditions included asthma (n = 209) and mental or behavioral health disorders (n = 146), including attention-deficit/hyperactivity disorder, autism, and developmental delays. Overall, 296 children (29.0%) had untreated decay, and 378 (37.0%) had caries experience (decayed and filled teeth). Accounting for sociodemographic characteristics, CSHCN had 34% reduced odds of untreated decay (adjusted odds ratio [AOR], 0.66 [95% CI, 0.48-0.92]) compared with those with without chronic disease. In addition, caries experience was lower among CSHCN (AOR, 0.79 [95% CI, 0.60-1.04]). In this cross-sectional study of Medicaid-enrolled children who attended well-child visits as preschoolers, untreated dental decay was lower among CSHCN compared with those without chronic conditions. This study suggests that CSHCN may have had better access to the various types of dental care facilitated in medical settings.

A decade of Clostridioides difficile infection: a constant challenge to maintain the status quo

Clostridioides difficile infection (CDI) is a leading cause of healthcare-associated (HA) diarrhoea. We retrospectively investigated data from a comprehensive, multidisciplinary C. difficile surveillance programme focusing on hospitalised patients in a tertiary Irish hospital over ten years.

Public guide for "first aid onsite-first responders action" in China (2023)

In order to improve the popularity of first aid knowledge among the public, First Aid Professional Committee of China Geriatric Health Care Association has formulated the Public guide for "first aid onsite-first responders action" in China (2023). This guide aims at providing with the first eyewitness action guide that are critical but weak onsite rescue link of Chinese emergency medical service system to the public. In the first scene of injury and illness emergencies, it is very important for the first eyewitness to make a prompt and correct response in the first time. Based on best practice evidence, this guide combs the core concepts of onsite first aid in order to provide guidance and help in standardizing the popularization of public first aid knowledge and skills.

Epidemiology, Clinical Features, and Antimicrobial Resistance of Invasive Escherichia Coli Disease in Patients Admitted in Tertiary Care Hospitals.

Invasive Escherichia coli disease (IED), including bloodstream infection, sepsis, and septic shock, can lead to high hospitalization and mortality rates. This multinational study describes the clinical profile of patients with IED in tertiary care hospitals. We applied clinical criteria of systemic inflammatory response syndrome (SIRS), sepsis, or septic shock to patients hospitalized with culture-confirmed E coli from urine or a presumed sterile site. We assessed a proposed clinical case definition against physician diagnoses. Most patients with IED (N = 902) were adults aged ≥60 years (76.5%); 51.9%, 25.1%, and 23.0% of cases were community-acquired (CA), hospital-acquired (HA), and healthcare-associated (HCA), respectively. The urinary tract was the most common source of infection (52.3%). Systemic inflammatory response syndrome, sepsis, and septic shock were identified in 77.4%, 65.3%, and 14.1% of patients, respectively. Patients >60 years were more likely to exhibit organ dysfunction than those ≤60 years; this trend was not observed for SIRS. The case-fatality rate (CFR) was 20.0% (60-75 years, 21.5%; ≥75 years, 22.2%), with an increase across IED acquisition settings (HA, 28.3%; HCA, 21.7%; CA, 15.2%). Noticeably, 77.8% of patients initiated antibiotic use on the day of culture sample collection. A total of 65.6% and 40.8% of E coli isolates were resistant to ≥1 agent in ≥1 or ≥2 drug class(es). A 96.1% agreement was seen between the proposed clinical case definition and physician's diagnoses of IED. This study contributes valuable, real-world data about IED severity. An accepted case definition could promote timely and accurate diagnosis of IED and inform the development of novel preventative strategies.

A Strategy To Prevent Acute Infections In Health Care Associations

A Strategy To Prevent Acute Infections In Health Care Associations

The impact of COVID-19 on clinical outcomes of burn patients

Abstract Background Multiple studies have shown the SARS-CoV-2 virus (COVID-19) to be associated with deleterious outcomes in a wide range of patients. The impact of COVID-19 has not been well investigated among burned patients. We suspect that patients will have worsened respiratory and thrombotic complications, ultimately leading to increased mortality. The objective of this study is to determine the impact a concurrent infection of COVID-19 has on clinical outcomes after a burn injury. Methods This is a retrospective, propensity matched, cohort study. We examined a de-identified database of electronic medical records of over 75 million patients across 75 health care associations in the United States for patients treated for thermal burns from 1 January 2020, to 31 July 2021, and those who also were diagnosed with COVID-19 infection within one day before or after injury based on International Classification of Disease, tenth revision (ICD-10) codes. Study participants included adults who were treated for a burn injury during the study period. Results We included 736 patients with burn injury and concomitant COVID-19 infection matched to 736 patients with burn injury and no concurrent COVID-19 infection (total 1472 patients, mean age 36.3 ± 24.3). We found no significant increase in mortality observed for patients with concurrent COVID-19 (OR 1.203, 95% CI 0.517–2.803; p = 0.6675). We did observe significant increase in infections (OR 3.537, 95% CI 2.798–4.471; p = 0.0001), thrombotic complications (OR 2.342, 95% CI 1.351–4.058; p = 0.0018), as was the incidence of hypertrophic scarring (OR 3.368, 95% CI 2.326–4.877; p = 0.0001). Conclusions We observed that concurrent COVID-19 infection was associated with an increase in infections, thrombosis and hypertrophic scarring but no increase in mortality in our cohort of burn patients.

Molecular Epidemiology, Clinical Course, and Implementation of Specific Hygiene Measures in Hospitalised Patients with Clostridioides difficile Infection in Brandenburg, Germany.

(1) Background: Clostridioides difficile infections (CDI) have increased worldwide, and the disease is one of the most common healthcare-associated infections (HAI). This study aimed to evaluate the molecular epidemiology of C. difficile, the clinical outcome, and the time of initiation of specific hygiene measures in patients with CDI in a large tertiary-care hospital in Brandenburg. (2) Methods: Faecal samples and data from hospitalised patients diagnosed with CDI were analysed from October 2016 to October 2017. The pathogens were isolated, identified as toxigenic C. difficile, and subsequently subtyped using PCR ribotyping and whole genome sequencing (WGS). Data regarding specific hygiene measures for handling CDI patients were collected. (3) Results: 92.1% of cases could be classified as healthcare-associated (HA)-CDI. The recurrence rate within 30 and 90 days after CDI diagnosis was 15.7% and 18.6%, and the mortality rate was 21.4% and 41.4%, respectively. The most frequent ribotypes (RT) were RT027 (31.3%), RT014 (18.2%), and RT005 (14.1%). Analysis of WGS data using cgMLST showed that all RT027 isolates were closely related; they were assigned to two subclusters. Single-room isolation or barrier measures were implemented in 95.7% patients. (4) Conclusions: These data show that RT027 is regionally predominant, thus highlighting the importance of specific hygiene measures to prevent and control CDI and the need to improve molecular surveillance of C. difficile at the local and national level.

410. Characteristics of Patients with Extended-Spectrum Beta-Lactamase (ESBL) Producing Enterobacterales, Tennessee, 2019-2020

Abstract Background Currently, data on the incidence of Enterobacterales bacteria that produce extended-spectrum beta-lactamases (ESBL) within community settings is lacking. We set out to describe patient characteristics for healthcare-associated (HA) and community-associated (CA) ESBL-producing Enterobacterales in Tennessee. Methods ESBL cases were defined as isolation of Escherichia coli, Klebsiella pneumoniae, or Klebsiella oxytoca, resistant to cefotaxime, ceftriaxone, or ceftazidime, non-resistant to all tested carbapenems, from a normally sterile body site, or urine, within Maury, Lewis, Marshall, or Wayne Counties, with a specimen collection date from July 1st, 2019, to the end of 2020. Patient data was collected by reviewing patients’ medical records. HA cases were defined as those with previous healthcare exposures, of any kind, in the year preceding specimen collection. All analysis was performed using SAS 9.4. Results 566 cases were included in this study. Demographically, 459 (81.1%) cases identified as white with an equal number (81.1%) of patients being female. The average age was 66.2 years. 560 (98.94%) specimens were collected from urine, 468 (85.1%) patients had a urinary tract infection (UTI), and 174 (37.2%) of those patients had a record of recurrent UTIs. 243 (49.6%) cases were identified as CA. 138 (24.4%) cases were identified as being hospitalized within 29 days of their specimen collection and 247 (50.4%) cases were determined to be HA. 142 (25.1%) patients were treated with antibiotic in the month before specimen collection. Cephalosporins (31.7%), fluroquinolones (29.6%), doxycycline (7.7%), and sulfonamides (7.7%) were the most common antibiotics used to treat the patients. Among patients prescribed these antibiotics (N=109), 19 (17.4%) patients had specimens resistant. Figure 1:Characteristics of patients with extended-spectrum beta-lactamases (ESBL) producing Enterobacterales isolated from 2019-2020Figure 2:Characteristics of patients with extended-spectrum beta-lactamases (ESBL) producing Enterobacterales isolated from 2019-2020, continued Conclusion Most cases were described in white women with UTIs, often recurrent, coming from private residences. With approximately 50% of cases described as CA, targeted intervention outside of healthcare facilities is necessary to reduce spread of ESBL infections. As 17.4% of cases were treated with antibiotics that the organism was resistant, there is an opportunity to improve judicial use of antibiotics based on susceptibility data. Disclosures All Authors: No reported disclosures.

Impact of discontinuing isolation in a private room for patients infected or colonized with vancomycin-resistant enterococci (VRE) on the incidence of healthcare-associated VRE bacteraemia in a hospital with a predominantly shared-room setting

Isolating patients infected or colonized with vancomycin-resistant enterococci (VRE) in a private room or cohort room to prevent hospital transmission is controversial. To evaluate the effect of a relaxed isolation policy for VRE-infected or colonized patients on healthcare-associated (HA) VRE bacteraemia in an acute care hospital with a predominantly shared-room setting. The incidence of HA VRE bacteraemia was compared during a private isolation era (October 2014-September 2017), a cohort isolation era (October 2017-June 2020), and a no isolation era (July 2020-June 2022). Using Poisson regression modelling, an interrupted time-series analysis was conducted to analyse level changes and trends in incidences of HA VRE bacteraemia for each era. The proportion of VRE-infected or -colonized patients staying in shared rooms increased from 18.3% in the private isolation era to 82.6% in the no isolation era (P < 0.001). There was no significant difference in the incidences of HA VRE bacteraemia between the private isolation era and the cohort isolation era (relative risk: 1.01; 95% confidence interval: 0.52-1.98; P= 0.977) or between the cohort isolation era and the no isolation era (0.99; 0.77-1.26; P= 0.903). In addition, there was no significant slope increase in the incidence of HA VRE bacteraemia between any of the eras. In a hospital with predominantly shared rooms, the relaxation of isolation policy did not result in increased HA VRE bacteraemia, when other infection control measures were maintained.

Evaluation of a statewide collaborative focused on antibiotic usage surveillance and stewardship in New York State Hospitals

To prepare NYS hospitals for reporting in The National Health Care Safety Network's Antimicrobial Use and Resistance (AUR) Module, the Health care Association of New York State (HANYS) launched a voluntary Antibiotic Stewardship Collaborative (ASC) in late 2015 with 2 aims (1) assist hospitals in developing the infrastructure necessary to track and report antibiotic usage; (2) educate hospitals on antibiotic stewardship. This study evaluates the characteristics of hospitals opting to participate in the ASC and their experiences in the program, as well as the effects of one year of participation (2016) on hospital-acquired C. difficile infection (HA-CDI) rates. Difference in means testing of clinical and non-clinical characteristics were performed to understand the "type" of hospital joining the ASC; semi-structured interviews were conducted to understand reasons for opting in or out of the ASC and experiences in the program; and a multivariate regression analysis with a difference-in-differences approach was used to assess the impact on HA-CDI rates. Hospitals with a greater number of annual discharges (P < .001) located in urban areas (P=.03) were more likely to join the ASC. All participants in the ASC (N=44/184) successfully implemented the necessary infrastructure to track and report antibiotic usage data, despite this being the most cited challenge and main reason hospitals opted not to participate. While HA-CDI rates decreased to a greater extent for participating hospitals (β=-0.153), this was not statistically significant (P=.191). HANYS' ASC proved an effective and well-received strategy for encouraging hospitals, particularly large, urban facilities, to take concrete steps to strengthen their antibiotic stewardship efforts and prepare for potential mandates requiring antibiotic usage tracking and reporting. However, a reduction in HA-CDI resulting from these efforts remains to be seen.

Early deaths associated with community-acquired and healthcare-associated bloodstream infections: a population-based study, Finland, 2004 to 2018.

BackgroundBloodstream infections (BSI) cause substantial morbidity and mortality.AimWe explored the role of causative pathogens and patient characteristics on the outcome of community-acquired (CA) and healthcare-associated (HA) BSI, with particular interest in early death.MethodsWe used national register data to identify all BSI in Finland during 2004–18. We determined the origin of BSI, patients´ underlying comorbidities and deaths within 2 or 30 days from specimen collection. A time-dependent Cox model was applied to evaluate the impact of patient characteristics and causative pathogens on the hazard for death at different time points.ResultsA total of 173,715 BSI were identified; 22,474 (12.9%) were fatal within 30 days and, of these, 6,392 (28.4%) occurred within 2 days (7.9 deaths/100,000 population). The 2-day case fatality rate of HA-BSI was higher than that of CA-BSI (5.4% vs 3.0%). Patients who died within 2 days were older than those alive on day 3 (76 vs 70 years) and had more severe comorbidities. Compared with other BSI, infections leading to death within 2 days were more often polymicrobial (11.8% vs 6.3%) and caused by Pseudomonas aeruginosa (6.2% vs 2.0%), fungi (2.9% vs 1.4%) and multidrug-resistant (MDR) pathogens (2.2% vs 1.8%), which were also predictors of death within 2 days in the model.ConclusionsOverrepresentation of polymicrobial, fungal, P. aeruginosa and MDR aetiology among BSI leading to early death is challenging concerning the initial antimicrobial treatment. Our findings highlight the need for active prevention and prompt recognition of BSI and appropriate antimicrobial treatment.

Reducing Carbapenem-Resistant Enterobacteriaceae Using the Targeted Solution Tool: A Quality Improvement Project.

Carbapenem-resistant Enterobacteriaceae (CRE) is a worldwide urgent health problem. Hand hygiene (HH) is an effective intervention to reduce the spread of CRE. In 2017, an increase in the rate of health care-associated (HA) CRE colonization was observed in a large multiorgan transplant center in Italy. This study aimed to reduce the HA-CRE colonization rates by improving HH compliance. A pre-/post-intervention project was conducted from November 2017 through December 2020. The DMAIC (Define, Measure, Analyze, Improve, and Control) framework was used to implement the HH Targeted Solution Tool (TST). Hand hygiene compliance increased from 49% to 76.9% after the Improve phase ( P = .0001), and to 81.9% after the second Control phase ( P = .0001). The rate of HA-CRE decreased from 24.9% to 5.6% ( P = .0001). Using the DMAIC framework to implement the TST can result in significant improvements in HH compliance and HA-CRE colonization rates.

Carbapenem-resistant Enterobacterales in patients with bacteraemia at tertiary academic hospitals in South Africa, 2019 - 2020: An update.

The emergence of carbapenem-resistant Enterobacterales (CRE) has become a serious and significant public health threat worldwide, owing to the limited antimicrobial therapy options, and the elevated mortality rates associated with these infections. To present an update on the epidemiology of CRE bloodstream infections among hospitalised patients reported under the Group for Enteric, Respiratory and Meningeal Diseases Surveillance in South Africa (GERMS-SA) between January 2019 and December 2020. Patients of all ages with CRE bacteraemia were included and isolates, when available, were sent to the reference laboratory for confirmatory testing and molecular characterisation. Multivariable logistic regression analysis was performed to assess factors associated with in-hospital mortality. We included 2 144 patients with CRE bacteraemia with a median age of 33 (interquartile range 1 - 51) years, of whom 1 145 (54.2%) were male. Klebsiella pneumoniae accounted for 79.8% of infections (n=863/1 082), of which 89.5% (n=611/683) were healthcare associated (HA). The most common carbapenemase genes were carbapenem-hydrolysing oxacillinase-48 (blaOXA-48-like) (76.8%; n=761/991), New Delhi metallo-β-lactamase (blaNDM) (21.1%; n=209/991) and Verona integron-encoded metallo-β-lactamase (blaVIM) (1.3%; n=13/991). None of the screened isolates with a colistin minimum inhibitory concentration >2 μg/mL harboured the mobilised colistin resistance (mcr)-1 to mcr-5 genes. The crude in-hospital mortality rate was 36.6% (n=377/1 029). Patients aged ≥60 years (v. 1.6 - 9 years) (adjusted odds ratio (aOR) 4.53; 95% confidence interval (CI) 2.21 - 9.28), those with comorbidities (diabetes, malignancy, renal and/or cardiovascular failure) (aOR 1.72; 95% CI 1.17 - 2.52), those with altered mental state (aOR 5.36; 95% CI 3.21 - 8.92) and those with previous antimicrobial use (aOR 1.88; 95% CI 1.27 - 2.77) had increased odds of in-hospital mortality. The epidemiology of CRE bloodstream infections remained similar compared with the previous surveillance report. Most infections were HA and caused by OXA-48-like carbapenemase-producing K. pneumoniae with no plasmid-mediated colistin resistance. Standard infection control measures should be strengthened.

An automated standalone hand wash outdoor deployment unit for infectious disease control

The recent global coronal virus pandemic raised increased awareness towards ideal hand hygiene procedures as promoted by World Health Organisation (WHO) and other related health care associations. Compliance to the prescribed procedure has been rather difficult as people gradually get accustomed to this effective hand wash habit, especially with regards the 20 s hand rub process. Traditional hand wash faucets with manual controls are prone to exposing users to recontamination or transmission of infectious deceases. Also, water wastage of 51.32% was observed from empirical studies. The designed automated standalone hand wash unit (ASHU) seeks to solve the contamination problem by running a contactless tap operation, while guiding users through the ideal hand wash procedure with the aid of visual and audio annunciators. Being a standalone unit, solar energy in used to power of the low power design system for uninterrupted outdoor operation, even in unelectrified rural regions. With the suitable level sensors and IoT infrastructure put in place, the unit maintenance operators are able to monitor the fluid levels in with the aid of a custom-built mobile app. Subsequently, the ASHU yields a water wastage potential of only a maximum of 13.31% and a user satisfaction guarantee for 93% of the refill cycle.

Integration of Sequencing and Epidemiologic Data for Surveillance of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infections in a Tertiary-Care Hospital.

BackgroundThe ongoing COVID-19 pandemic significantly burdens hospitals and other healthcare facilities. Therefore, understanding the entry and transmission of SARS-CoV-2 is critical for effective prevention and preparedness measures. We performed surveillance and analysis of testing and transmission of SARS-CoV-2 infections in a tertiary-care hospital in Germany during the second and third pandemic waves in fall/winter 2020.MethodsBetween calendar weeks 41/2020 and 1/2021 40% of all positive patient and staff samples (284 total) were subjected to full-length viral genome sequencing. Clusters were defined based on similar genotypes indicating common sources of infection. We integrated phylogenetic, spatial, and temporal metadata to detect nosocomial infections and outbreaks, uncover transmission chains, and evaluate containment measures’ effectiveness.ResultsEpidemiologic data and contact tracing readily recognize most healthcare-associated patient infections. However, sequencing data reveal that temporally preceding index cases and transmission routes can be missed using epidemiologic methods, resulting in delayed interventions and serially linked outbreaks being counted as independent events. While hospital-associated transmissions were significantly elevated at a moderate rate of community transmission during the second wave, systematic testing and high vaccination rates among staff have led to a substantial decrease in healthcare-associated infections at the end of the second/beginning of the third wave despite high community transmissions.ConclusionsWhile epidemiologic analysis is critical for immediate containment of healthcare-associated SARS-CoV-2 outbreaks, integration of genomic surveillance revealed weaknesses in identifying staff contacts. Our study underscores the importance of high testing frequency and genomic surveillance to detect, contain and prevent SARS-CoV-2-associated infections in healthcare settings.

Trends in methicillin-resistant Staphylococcus aureus in the Gulf Cooperation Council countries: antibiotic resistance, virulence factors and emerging strains.

Methicillin-resistant Staphylococcus aureus (MRSA) is a ubiquitous pathogen that is increasing in Gulf Cooperation Council (GCC) countries. It is implicated in a wide range of infections, from superficial skin infections to lifethreatening syndromes. MRSA has moved beyond healthcare facilities, affecting individuals in the community without substantial risk factors. To review the prevalence and molecular characterization of MRSA in GCC countries during 2011-2021. We comprehensively searched PubMed using the following keywords: MRSA, Staphylococcus aureus, GCC, Kuwait, Saudi Arabia, Bahrain, Oman, Qatar, UAE, prevalence, and molecular characterization for articles published after 2011. Thirty-nine of 111 articles examined, fulfilled the purpose of this review. Most studies were in Kuwait (44%), Saudi Arabia (28%) and United Arab Emirates (10%). Studies from other GCC countries were sporadic. Several studies demonstrated a clear emergence in antibiotic resistance especially against fusidic acid, ciprofloxacin and clindamycin. Regional prevalence of MRSA is reported as 25-35%, with clear dominance of community-acquired (CA)-MRSA. Panton- Valentine leucocidin (PVL)-producing strains accounted for 35-45%, with clear association with CA-MRSA emergence, but there were some sporadic reports of incorporation of PVL in healthcare-associated (HA)-MRSA. The reported dominant strains included EUST80, USA1100 and WA-MRSA-51. Novel strains are more likely to produce PVL and show fusidic acid resistance. There is a need for national and regional MRSA surveillance programmes, especially with the emergence of strains that require no underlying risk factors to cause illness, as well as the propagation of chimeric resistance elements in both HA-MRSA and CA-MRSA.

Clinical and microbiological risk factors for community-associated Clostridioides difficile infections

Background: The incidence of community-associated (CA) Clostridioides difficile infection (CDI) has increased in Korea. In this study, we evaluated CA-CDI risk factors in terms of clinical features and ribotype considering its region-specific molecular epidemiology. Methods: A retrospective case-control study was performed on two groups of CDI patients: 127 subjects with CA-CDI and 265 subjects with healthcare-associated (HA)-CDI. Risk factors for CA-CDI were evaluated in terms of clinical and microbiological features such as toxin type and ribotype. Results: A comparison of the two groups of CDI patients revealed that inflammatory bowel disease, diarrhea, abdominal pain, and fever were more closely associated with CA-CDI. The toxin types and ribotypes of C. difficile were similar between the two groups. After adjusting for variables, no risk factors were identified for CA-CDI compared with HA-CDI. Conclusion: Specific risk factors for CA-CDI were not identified in this study.

Characterization of Healthcare-Associated and Community-Associated Clostridioides difficile Infections among Adults, Canada, 2015-2019.

We investigated epidemiologic and molecular characteristics of healthcare-associated (HA) and community-associated (CA) Clostridioides difficile infection (CDI) among adult patients in Canadian Nosocomial Infection Surveillance Program hospitals during 2015–2019. The study encompassed 18,455 CDI cases, 13,735 (74.4%) HA and 4,720 (25.6%) CA. During 2015–2019, HA CDI rates decreased by 23.8%, whereas CA decreased by 18.8%. HA CDI was significantly associated with increased 30-day all-cause mortality as compared with CA CDI (p<0.01). Of 2,506 isolates analyzed, the most common ribotypes (RTs) were RT027, RT106, RT014, and RT020. RT027 was more often associated with CDI-attributable death than was non-RT027, regardless of acquisition type. Overall resistance C. difficile rates were similar for all drugs tested except moxifloxacin. Adult HA and CA CDI rates have declined, coinciding with changes in prevalence of RT027 and RT106. Infection prevention and control and continued national surveillance are integral to clarifying CDI epidemiology, investigation, and control.

Evaluation of the genomic epidemiology and transmission of Clostridioides difficile infection across a community

Background:Clostridioides difficile infection (CDI) is a major cause of morbidity and healthcare costs in the United States. The epidemiology of CDI has recently shifted, with healthcare-associated (HCA) CDI trending downward and community-associated (CA)-CDI becoming more prominent. The cause of this shift is not well understood but may be related to changing genomic epidemiology. We assessed C. difficile strains across a CDC Emerging Infections Program (EIP) site in Western New York, including strains from both HCA-CDI and CA-CDI cases to characterize predominating strains and putative transmission across epidemiological classifications and between index and recurrent cases. Methods: In total, 535 isolates of C. difficile were collected over a 6-month period in 2018 from the Monroe Country, New York, EIP site and were analyzed using whole-genome sequencing (WGS). Standard epidemiological definitions were used to classify cases as hospital onset (HO-CDI); community associated (CA-CDI); community onset, healthcare associated (CO-HCFA-CDI); or long-term care onset (LTCO-CDI). Recurrent cases were defined as those diagnosed within 8 weeks of an initial positive test. Multilocus sequence types (MLSTs) were assigned according to PUBMLST and single-nucleotide polymorphisms (SNPs) were determined using a modified CFSAN analytical pipeline. Cases resulting from putative transmission were defined as those separated by 0–1 core SNPs. Results: Of 535 isolates, 454 were from index and 81 were from recurrent cases. The index cases were comprised of CA-CDI (47.4%), CO-HCFA-CDI (24%), LTCO-CDI (8.1%), and HO-CDI (19.3%). Cases with recurrent disease mirrored the epidemiological distribution of the larger set. Common MLSTs included ST2 (12.3%), ST8 (10.5%), ST42 (7.9%), ST58 (4.9%), ST43 (4.5%), and ST11 (4.3%). The previously widespread epidemic strain, NAP1/ST1/RT027 accounted for Conclusions: The genomic epidemiology of C. difficile across this large community cohort demonstrated a diverse group of strain types that was similarly distributed across epidemiological classifications and between index and recurrent cases. SNP analysis indicated that direct transmission between cases was uncommon.Funding: NoneDisclosures: None

Order Substitutions and Education for Balanced Crystalloid Solution Use in an Integrated Health Care System and Association With Major Adverse Kidney Events

Trials comparing balanced crystalloids with normal saline have yielded mixed results regarding reductions in kidney complications and mortality for hospitalized patients receiving intravenous fluids. To evaluate the association of a multifaceted implementation program encouraging the preferential use of lactated Ringer solution with patient outcomes and intravenous fluid-prescribing practices in a large, multilevel health care system. This type 2 hybrid implementation and comparative effectiveness study enrolled all patients 18 years or older who received 1 L or more of intravenous fluids while admitted to an emergency department and/or inpatient unit at 1 of 22 hospitals in Idaho and Utah between November 1, 2018, and February 29, 2020. An interrupted time series analysis was used to assess study outcomes before and after interventions to encourage use of lactated Ringer solution. Implementation program combining order set modification, electronic order entry alerts, and sequential clinician-targeted education to encourage prescribing of lactated Ringer solution instead of normal saline. The primary implementation outcome was the patient-level proportion of intravenous fluids that was balanced crystalloids. The primary effectiveness outcome was the incidence of major adverse kidney events (MAKE30)-a composite of new persistent kidney dysfunction, new initiation of dialysis, and death-at 30 days. Among 148 423 patients (median [IQR] age, 47 [30-67] years; 91 302 women [61%]), the proportion of total fluids received that was lactated Ringer solution increased from 28% to 75% in the first week vs the last week of the study (immediate implementation effect odds ratio [OR], 3.44; 95% CI, 2.79-4.24). The estimated MAKE30 absolute risk reduction was 2.2% (95% CI, 1.3%-3.3%) based on interrupted time series analysis showing a decrease in the week-on-week trend for MAKE30 (OR difference, 0.03; 95% CI, 0.03-0.03, P < .001). The immediate postimplementation OR for MAKE30 was 0.88 (95% CI, 0.76-1.01), with a decrease in persistent kidney dysfunction (OR, 0.80; 95% CI, 0.69-0.93) and mortality (OR, 0.78; 95% CI, 0.65-0.93) but not dialysis (OR, 1.00; 95% CI, 0.76-1.32). In this comparative effectiveness study, an implementation program was associated with an increase in the proportion of fluids administered as lactated Ringer solution compared with normal saline and was associated with a reduction in MAKE30 events among patients treated in a large integrated health care system.