Healthcare Epidemiology Research Articles

929. A Nationwide Survey on the Role of Antimicrobial Stewardship Programs during the COVID-19 Pandemic: What is restricted and who decides?

Abstract Background During the COVID-19 pandemic, evolving literature and emerging therapies have led to significant controversies on what constitutes optimal therapy for hospitalized patients with COVID-19. In addition, multiple guidelines emerged exhibiting variable recommendations in key areas of therapeutic management. Thus, interpreting emerging data and deploying novel therapeutics during the pandemic has been challenging. Antimicrobial stewardship programs (ASP) have been proven to help promote evidence-based practices and are now common the United States (US). We seek to further understand the role of ASP during the COVID-19 pandemic. Methods A survey was developed and disseminated through Infectious Diseases Society of America (IDSA) IDea network, IDSA Antimicrobial Stewardship Centers for Excellence and the Society for Healthcare Epidemiology messaging boards. Data collected included city, hospital size, facility type, and existence of active ASP. COVID-19 therapeutic restrictions and type of provider who decides on treatment allocation was surveyed. Results A total of 92 surveys were completed, representing wide geographic reach within the United States (Figure 1). Hospital size by beds were 14% less than 200 (13), 18.5% 201-300 beds (17), 15.2% 301-400 beds (14), and 52.2% over 400 beds (48). Community hospitals accounted for 31.5% (29), county/public hospital 3.3% (3, 3.3%), University-affiliated Community-Based Teaching Hospitals 10.9% (10), University-based Teaching Hospital 45.7% (42), and 8.7% selected other. ASP were present in 97.2% of hospitals. COVID-19 therapeutic restrictions were common (Figure 2). Infectious diseases (ID) approval was required in 87.9% of facilities (Figure 3). Figure 1Geographic distribution of hospitals represented in the survey Figure 2. Restricted COVID-19 therapies by medication type (%) Figure 3 Specialties or providers that are able to order or approve restricted COVID-19 therapies (%) Conclusion COVID-19 therapeutics were commonly restricted during the COVID-19 pandemic. Approval by ID clinicians was required almost universally (87.9%). The role of other specialties was significantly lower, representing less than 45% of hospitals. ID clinicians have played a vital role in guiding therapy and supporting ASP during the COVID-19 pandemic. This survey highlights the value of ID clinicians to healthcare systems in allocating resources and promoting evidence-based practices through ASP. Disclosures All Authors: No reported disclosures.

Temporal trends in microbial detection during the COVID-19 pandemic: Analysis of the Japan surveillance for Infection Prevention and Healthcare Epidemiology (J-SIPHE) database

The impact of the COVID-19 pandemic on the incidence of microbial infections and other metrics related to antimicrobial resistance (AMR) has not yet been fully described. Using data from Japan Surveillance for Infection Prevention and Healthcare Epidemiology (J-SIPHE), a national surveillance database system that routinely collects clinical and epidemiological data on microbial infections, infection control practices, antimicrobial use, and AMR emergence from participating institutions in Japan, we assessed the temporal changes in AMR-related metrics before and after the start of the COVID-19 pandemic. We found that an apparent decrease in the incidence of microbial infections in 2020 compared with 2019 may have been driven primarily by a reduction in bed occupancy, although the incidence showed a constant or even slightly increasing trend after adjusting for bed occupancy. Meanwhile, we found that the incidence of Streptococcus pneumoniae dramatically decreased from April 2020 onward, probably due to stringent non-pharmaceutical interventions against COVID-19. Antimicrobial use showed a weak increasing trend, while the use of hand sanitiser at the included medical institutions increased by about 50% in 2020 compared with 2019.

Is Three Company or a Crowd? Comparing and Contrasting U.S. and European Clostridioidesdifficile Clinical Practice Guidelines.

In 2021, the American College of Gastroenterology (ACG), the Infectious Diseases Society of America in conjunction with the Society for Healthcare Epidemiology of America (IDSA/SHEA), and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) published updated clinical practice guidelines (CPGs) for the management of Clostridioides difficile infections. The differences, sometimes subtle, between these guideline recommendations have caused some debate among clinicians. This paper delves into select key recommendations from each respective CPG and analyzes the differences and evidence associated with each. One primary difference between the CPGs is the preference given to fidaxomicin over vancomycin for initial treatment in non-severe and severe disease endorsed by IDSA/SHEA and ESCMID guidelines, while the ACG-sponsored CPGs do not offer a preference. The emphasis on cost effective data was also a noticeable difference between the CPGs and thus interpretation of the available evidence. When using guidelines to help support local practice or institutional treatment pathways, clinicians should carefully balance CPG recommendations with local patient populations and feasibility of implementation, especially when multiple guidelines for the same disease state exist.

Leadership in healthcare epidemiology, antimicrobial stewardship, and medicine: A soccer enthusiast's perspective.

Leadership in healthcare epidemiology, antimicrobial stewardship, and medicine: A soccer enthusiast's perspective.

Clostridioides difficile Infection in Children-An Update.

Clostridioides difficile Infection in Children-An Update.

Impact of Updated Clinical Practice Guidelines on Outpatient Treatment for Clostridioides difficile Infection and Associated Clinical Outcomes.

BackgroundThe 2017 Infectious Diseases Society of America/Society for Healthcare Epidemiology of America (IDSA/SHEA) Clostridium (Clostridioides) difficile infection (CDI) guideline update recommended treatment with fidaxomicin or vancomycin for CDI. We aimed to examine outpatient CDI treatment utilization before and after the guideline update and compare clinical outcomes associated with fidaxomicin versus vancomycin use.MethodsA pre-post study design was employed using Medicare data. CDI treatment utilization and clinical outcomes (4- and 8-week sustained response, CDI recurrence) were compared between patients indexed from April–September 2017 (preguideline period) and those indexed from April–September 2018 (postguideline period). Clinical outcomes associated with fidaxomicin versus vancomycin were compared using propensity score–matched analyses.ResultsFrom the pre- to postguideline period, metronidazole use decreased (initial CDI: 81.2% to 53.5%; recurrent CDI: 49.7% to 27.6%) while vancomycin (initial CDI: 17.9% to 44.9%; recurrent CDI: 48.1% to 66.4%) and fidaxomicin (initial CDI: 0.87% to 1.63%; recurrent CDI: 2.2% to 6.0%) use increased significantly (P < .001 for all). However, clinical outcomes did not improve. In propensity score–matched analyses, fidaxomicin versus vancomycin users had 4-week sustained response rates that were higher by 13.5% (95% confidence interval [CI], 4.0%–22.9%; P = .0058) and 30.0% (95% CI, 16.8%–44.3%; P = .0002) in initial and recurrent CDI cohorts, respectively. Recurrence rates were numerically lower for fidaxomicin in both cohorts.ConclusionsVancomycin use increased and metronidazole use decreased after the 2017 guideline update. Fidaxomicin use increased but remained low. Improved outcomes associated with fidaxomicin relative to vancomycin suggest benefits from its greater use in Medicare patients.

Time to evaluate decision support systems for antimicrobial prescribing outside the hospital

Time to evaluate decision support systems for antimicrobial prescribing outside the hospital

2022 adult immunization schedule updates

Each year, the U.S. Centers for Disease Control and Prevention (CDC) releases the adult vaccine schedule. The 2022 adult vaccine schedule has several changes which will be discussed in the following manuscript. The Advisory Committee on Immunization Practices reviews the preliminary schedules usually at their October or November meetings. The following professional societies also approve the adult schedules prior to the 2022 publications: American College of Physicians (ACP), American Academy of Family Physicians (AAFP), American College of Obstetricians and Gynecologists (ACOG), American College of Nurse-Midwives (ACNM), American Academy of Physician Assistants (AAPA) and the Society for Healthcare Epidemiology of America (SHEA). Once the final draft is approved by the CDC, it is published in the Morbidity and Mortality Weekly Report (MMWR) and released to healthcare providers and the general public with a cover page, tables, notes and—new for the 2022 schedule—an appendix with contraindications and precautions for the different approved vaccines.

Reporting behaviors and perceptions toward the National Healthcare Safety Network antimicrobial use (AU) and antimicrobial resistance (AR) modules.

To identify characteristics of US health systems and end users that report antimicrobial use and resistance (AUR) data, to determine how NHSN AUR data are used by hospitals and health systems and end users, and to identify barriers to AUR reporting. An anonymous survey was sent to Society of Infectious Diseases Pharmacists (SIDP) and Society for Healthcare Epidemiology of America (SHEA) Research Network members. Data were collected via Survey Monkey from January 21 to February 21, 2020. Respondent and hospital data were analyzed using descriptive statistics. We received responses from 238 individuals across 43 US states. Respondents were primarily pharmacists (84%), from urban areas, (44%), from nonprofit medical centers (81%), and from hospitals with >250 beds (72%). Also, 62% reported data to the AU module and 19% reported data to the AR module. Use of software for local AU or AR tracking was associated with increased reporting to the AU module (19% vs 64%) and the AR module (2% vs 30%) (P < .001 each). Only 36% of those reporting data to the AU module used NHSN AUR data analysis tools regularly and only 9% reported data to the AR module regularly. Technical challenges and time and/or salary support were the most common barriers to AUR participation cited by all respondents. Among those not reporting AUR data, increased local expectations to report and better software solutions were the most commonly identified solutions to increase AUR reporting. Efforts to increase AUR reporting should focus on software solutions and salary support for data-entry activities. Increasing expectations to report may incentivize local resource allocation to improve AUR reporting rates.

Correlation between antibiotic use and antibiotic resistance: A multicenter study using the Japan Surveillance for Infection Prevention and Healthcare Epidemiology (J-SIPHE) system in Hokkaido, Japan

BackgroundThe Japan Surveillance for Infection Prevention and Healthcare Epidemiology (J-SIPHE) system aggregates information related to antimicrobial resistance (AMR) measures in participating medical institutions nationwide and is intended to be used for promotion of AMR measures in participating facilities and their communities. This multicenter study aimed to determine the usefulness of the J-SIPHE system for evaluating the correlation between antibiotic use and antibiotic resistance in Hokkaido, Japan. MethodsData on antibiotic use and detection rate of major resistant Gram-negative bacteria at 19 hospitals in 2020 were collected from the J-SIPHE system, and data correlations were analyzed using JMP Pro. ResultsThe detection rate of carbapenem-resistant Pseudomonas aeruginosa was significantly positively correlated with carbapenem use (Spearman's ρ = 0.551; P = .015). There were significant positive correlations between the detection rate of fluoroquinolone-resistant Escherichia coli and the use of piperacillin/tazobactam, carbapenems, and quinolones [ρ = 0.518 (P = .023), ρ = 0.76 (P < .001), and ρ = 0.502 (P = .029), respectively]. ConclusionsThis is the first multicenter study to investigate the correlation between antibiotic use and antibiotic resistance using the J-SIPHE system. The results suggest that using this system may be beneficial for promoting AMR measures.

Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update.

The purpose of this document is to highlight practical recommendations to assist acute care hospitals to prioritize and implement strategies to prevent ventilator-associated pneumonia (VAP), ventilator-associated events (VAE), and non-ventilator hospital-acquired pneumonia (NV-HAP) in adults, children, and neonates. This document updates the Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology (SHEA), and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America, the American Hospital Association, the Association for Professionals in Infection Control and Epidemiology, and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.

Monitoring disparities in healthcare-associated infection surveillance: A SHEA Research Network (SRN) Survey

Background: Inequities are seen in many health-related outcomes, and systemic and structural factors result in inequitable care based on social determinants of health (SDOH). However, whether disparities exist specifically in healthcare-associated infections (HAIs) based on these factors has not been well described. Furthermore, there are no national standards on whether information related to equity and SDOH should be included in HAI surveillance and how such information could be used. Methods: We surveyed US members of the SHEA Research Network (SRN), a consortium of healthcare facilities with leaders interested in healthcare epidemiology and infection prevention, via an online REDCap survey from October to December 2021. Results: Of the 68 eligible US SRN facilities, 28 (41%) responded. Among them, 27 institutions provide direct patient care and were analyzed. Of these 27 facilities, 8 (30%) collected data regarding variables related to equity including language for care, race or ethnicity, insurance status, and other. Of these faclilities, 38% are collecting but not otherwise using this information; other facilities use this information for a variety of reporting and intervention purposes (Fig. 2). Only 3 facilities (11%) analyzed whether disparities exist in any HAI rates. The most common barrier to collecting SDOH information is that facilities have not considered doing this work (Fig. 3). Of the 15 facilities not yet undertaking such work, 10 (67%) were interested in doing so. Specific recommendations about how to operationalize such collection are needed (Table 1). Conclusions: Most institutions in this sample are not collecting data that would allow for assessment of disparities in the rates of HAIs; however, there is interest in doing so. A minority of early adopter facilities are assessing whether disparities exist and are designing interventions. National guidance can play a key role in standardizing the collection of this information and translating early findings to identify and subsequently improve disparities within HAIs.Funding: NoneDisclosures: None

Genesis of Antibiotic Resistance (AR) LXXXIX: Turbulence Modeling(TM) of Hemodynamics in Simplified Severe Sepsis Protocol‐2 (SSSP‐2)‐NCT01663701: Global Alliance for an Integrated Data Base on Antibiotic(AR)/Antimicrobial(AMR)Susceptibility Test Interpretive Criteria (Breakpoints) (STIC), to mitigate AR Pandemic(ARP) in turn Fetter Modalities of Neuro(logy)) Psychiatry

Problem Statement and Rationale: Unpredictable nature of fluid dynamic/mechanical properties of circulation, subsequent to ERP‐EGDT, in part attributed to multiple classes of antibiotics (met. Breakdown products, adducts), administered across the globe Tx, sepsis with CC, MCC, DDx, Rx, PX., impeded the TM of ZoO @ LPE vortices, control of VKVS, BLS on ISP surpassing GCS 3‐8 to ihm. To obtain a reasonable understanding of the factors governing, antimicrobial stewardship (AS), and STIC, which are intrinsically strewn across the globe, we have completed a review focused on its effective utilization in TM of ERP‐EGDT, Tx severe sepsis: Part I: Analysis and Presentation of Cumulative Antimicrobial Susceptibility Test Data; Approved Guideline‐4ed. CLSI document M39‐A4. PA; CLSI: 2014; Part II: CLSI‐M‐100‐ED31:2021 CLSI, 31st Edition, Part III: Potential approach to susceptibility testing and management of MDR pathogens by Infectious Diseases Society of America(IDSA) Guidance on the Treatment of Antimicrobial Resistant Gram‐Negative Infections, Part IV: Antimicrobial Use and Resistance (AUR) Options: Resources: protocols, data collection forms &amp; instructions, data validation, supporting materials; Part V: Implementing an Antibiotic Stewardship Program: Guidelines by the IDSA and the Society for Healthcare Epidemiology of America, Part VI: Stewardship Assist, Antimicrobial Stewardship App. Taken together, it would be reasonable to pray that premier global health agencies such as WHO, organize a “World Congress of AR‐AMR” on an annual basis where experts on AR/AMR across the globe explore/exchange ideas to mitigate ARP. Also, to reach consensus for a centralized (agency) database for reporting on the complete information from multiple stakeholders across the globe on AF, DRI, RM, STIC, and AS strategies with a renewed focus in the area of: a comprehensive report on the list of routinely tested antibiotics (from county, city, state, country, continental), susceptible, intermediate, the pandemic potential of AR pathogens, list of unused/discontinued antibiotics/antimicrobials, confirmed list of first AR bacterial pathogen isolates,(“Pan Resistant Isolate”: ex: pan resistance enterobacter) of MDR, XDR, &amp; PDR (CRE/CRPA, CRAB), list of novel antibiotics against MDR, XDR, PDR; its pharmacokinetics/pharmacodynamics of (CminMIC, CmaxMIC, AUC:MIC), and workflow pathways for conventional and rapid diag. testing. Such an effect will definitely confer a better understanding of the impact of antibiotics (Jarisch Herxheimer Reaction @JHR‐neuropsychiatry), toxicity profile on vortices formation, control of VKVS in TM to achieve the dream to identify the point of care intervention for mitigating mortality in ERP‐EGDT. (Ack: Source: Subburaj Kannan, M.D., Ph.D., attended MyCE‐Harvard Medical School, MA “Antimicrobial Resistant Gram‐Negative Infections:”, on 11/03/21).

Cost-effectiveness of Fecal Microbiota Transplantation for First Recurrent Clostridioides difficile Infection.

Both the American College of Gastroenterology and the Infectious Diseases Society of America (IDSA)/Society for Healthcare Epidemiology of America 2021 Clostridioides difficile infection (CDI) guidelines recommend fecal microbiota transplantation (FMT) for persons with multiple recurrent CDI. Emerging data suggest that FMT may have high cure rates when used for first recurrent CDI. The aim of this study was to assess the cost-effectiveness of FMT for first recurrent CDI. We developed a Markov model to simulate a cohort of patients presenting with initial CDI infection. The model estimated the costs, effectiveness, and cost-effectiveness of different CDI treatment regimens recommended in the 2021 IDSA guidelines, with the additional option of FMT for first recurrent CDI. The model includes stratification by the severity of initial infection, estimates of cure, recurrence, and mortality. Data sources were taken from IDSA guidelines and published literature on treatment outcomes. Outcome measures were quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs). When FMT is available for first recurrent CDI, the optimal cost-effective treatment strategy is fidaxomicin for initial nonsevere CDI, vancomycin for initial severe CDI, and FMT for first and subsequent recurrent CDI, with an ICER of $27 135/QALY. In probabilistic sensitivity analysis at a $100 000 cost-effectiveness threshold, FMT for first and subsequent CDI recurrence was cost-effective 90% of the time given parameter uncertainty. FMT is a cost-effective strategy for first recurrent CDI. Prospective evaluation of FMT for first recurrent CDI is warranted to determine the efficacy and risk of recurrence.

Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older - United States, 2022.

At its November 2021 meeting, the Advisory Committee on Immunization Practices* (ACIP) approved the Recommended Adult Immunization Schedule for Ages 19 Years or Older, United States, 2022. The 2022 adult immunization schedule summarizes ACIP recommendations, including several changes to the cover page, tables, and notes from the 2021 immunization schedule.† In addition, the 2022 adult immunization schedule provides an appendix that lists the contraindications to and precautions for all routinely recommended vaccines in the schedule. This schedule can be found on the CDC immunization schedule website (https://www.cdc.gov/vaccines/schedules). Health care providers are advised to use the cover page, tables, notes, and appendix together. This adult immunization schedule is recommended by ACIP (https://www.cdc.gov/vaccines/acip) and approved by CDC (https://www.cdc.gov), the American College of Physicians (https://www.acponline.org), the American Academy of Family Physicians (https://www.aafp.org), the American College of Obstetricians and Gynecologists (https://www.acog.org), the American College of Nurse-Midwives (https://www.midwife.org), the American Academy of Physician Associates (https://www.aapa.org), and the Society for Healthcare Epidemiology of America (https://www.shea-online.org).

Recommended Adult Immunization Schedule, United States, 2022.

Recommended Adult Immunization Schedule, United States, 2022.

Clostridioides difficile toxin B gen amplification cycle threshold as a predictor of severity

Clostridioides dfficile infection (CDI) is the main cause of nosocomial diarrhea, generally associated with the use of antibiotics. This infection can cause uncomplicated diarrhea to pseudomembranous colitis or toxic megacolon. Recent studies have attempted to relate the threshold cycle (Ct) value of RT-PCR with mortality, as a fast, simple, objective and efficient method. To evaluate Ct as a predictor of poor outcome in patients with C. dfficile disease with/without clinical signs of severity. We carried out a retrospective study between January 2015 and December 2018, including all patients in the reference area of the Hospital Universitario de Canarias in Tenerife (396,483 inhabitants) in patients with clinical criteria of severity and patients without clinical severity criteria (according to the guide for the clinical practice of CDI of the Society of Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of North America (IDSA). A total of 202 CDI episodes were diagnosed. 77.7% (n = 157) presented clinical severity criteria. The presence of ulcerative colitis (p < 0.001), fever (p < 0.001), leukocytosis (p < 0.001), neutrophilia (p < 0.001), creatininemia (p = 0.005) were presented as risk factors for the development of severe CDI (S-CDI). Female sex, institutionalization, previous admission and death were described more frequently in the group with S-CDI, not finding significant differences. We found no differences with respect to the days of previous stay, or of post-CDI stay, although in the latter, the mean was higher in the case of S-CDI patients. No significant differences were found in terms of Ct in both groups; being only one point lower in patients with severity criteria (Ct = 26.1) than without severity criteria (Ct = 27.4) (p = 0.326). Conclusión: Based on the results of our study, it has not been possible to systematically implement the Ct value as a predictor of severity to the clinical report, and it is not possible to extrapolate this predictive variable from S-CDI and standardize the Ct value as a predictor of severity. Basándonos en los resultados de nuestro estudio, no ha sido posible la implementación sistemática del valor Ct como predictor de gravedad al informe clínico, no siendo posible extrapolar esta variable predictora de enfermedad por C difficile-G y estandarizar el valor Ct como factor predictor de gravedad.

Coronavirus disease 2019 (COVID-19) research agenda for healthcare epidemiology

Coronavirus disease 2019 (COVID-19) research agenda for healthcare epidemiology

Air exchanges, climate change, and severe acute respiratory coronavirus virus 2 (SARS-CoV-2): Results from a survey of the Society of Healthcare Epidemiology of America Research Network (SRN).

In this cross-sectional survey, we assessed knowledge, attitudes and behaviors regarding operating room air-change rates, climate change, and coronavirus disease 2019 (COVID-19) pandemic implications. Climate change and healthcare pollution were considered problematic. Respondents checked air exchange rates for COVID-19 and ∼25% increased them. Respondents had difficulty completing questions concerning hospital heating, ventilation and air conditioning (HVAC) systems.

Antibiotic prophylaxis practices in neurosurgery: A Society for Healthcare Epidemiology of America (SHEA) survey.

Antibiotic prophylaxis practices in neurosurgery: A Society for Healthcare Epidemiology of America (SHEA) survey.