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We analyzed invasive group A streptococcal puerperal sepsis cases in a large health zone in Alberta, Canada between 2013 and 2022. Of the 21 cases, 85.7% were adjudicated as hospital/delivery-acquired, with 2 clusters having identical isolates found through whole genome sequencing. We implemented policy interventions across Alberta aimed at preventing future infections.

Objectives: Post-marketing surveillance of sotrovimab's effect during implementation in the Canadian population is limited., Methods: The study used a propensity score-matched retrospective cohort design. Follow-up began between the periods of December 15, 2021 and April 30 2022. The study assessed any severe outcome defined as all-cause hospital admission or mortality within 30 days of a confirmed COVID-19-positive test. Covariate-adjusted odds ratios between sotrovimab treatment and the severe outcome was conducted using logistic regression., Results: There were 22,289 individuals meeting the treatment criteria for sotrovimab. There were 1603 treated and 6299 untreated individuals included in the analysis. The outcome occurrence in the study was 5.49% (treated) and 4.21% (untreated), with a median time from diagnosis to treatment of 1.00 days (interquartile range 2.00 days). In the propensity-matched cohort, sotrovimab was not associated with lower odds of a severe outcome (odds ratio 1.20, 95% confidence interval 0.91-1.58), adjusting for confounding variables., Conclusions: After adjusting for confounding variables, sotrovimab treatment was not associated with lower odds of a severe outcome within 30-days of COVID-19-positive date., Competing Interests: Declarations of competing interest The authors have no competing interests to declare., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: To evaluate the feasibility and effectiveness of a silver oxynitrate (Ag 7 NO 11 ) dressing on wound healing in patients with stalled chronic wounds., Methods: A prospective pilot study was conducted to determine the feasibility and effect of using silver oxynitrate dressings within an outpatient setting in Alberta, Canada. A total of 23 patients (12 women and 11 men; mean age, 66.1 ± 13.8 years) with a chronic wound that failed to heal with conventional treatment were included in the study. Wound assessments including the Bates-Jensen Wound Assessment Tool, wound-related pain, wound size, and patient quality of life (QoL) were conducted at baseline, after dressing application for 1 and 2 weeks, and during 4- and 12-week follow-ups., Results: Dressing application at 1 and 2 weeks improved patients' wound healing progression as measured through significantly decreased Bates-Jensen Wound Assessment Tool scores with a more than 10% decrease at 4- and 12-week follow-up ( P < .001). Pain ( P = .004), and QoL psyche subscore ( P = .008) significantly improved at 4-week follow-ups, although wound area, perimeter, and QoL body and everyday subscores were not significantly affected. Wound size was not significantly affected., Conclusions: The silver oxynitrate dressing may improve healing progression in patients with chronic wounds, enhance patient experience by reducing wound-related pain, and improve patients' mental well-being. Further studies are warranted to elucidate the effect of silver oxynitrate dressings on wound area, perimeter, and volume measurements., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To evaluate the impact of administering probiotics to prevent Clostridioides difficile infection (CDI) among patients receiving therapeutic antibiotics., Design: Stepped-wedge cluster-randomized trial between September 1, 2016, and August 31, 2019., Setting: This study was conducted in 4 acute-care hospitals across an integrated health region., Patients: Hospitalized patients, aged ≥55 years., Methods: Patients were given 2 probiotic capsules daily (Bio-K+, Laval, Quebec, Canada), containing 50 billion colony-forming units of Lactobacillus acidophilus CL1285, L. casei LBC80R, and L. rhamnosus CLR2. We measured hospital-acquired CDI (HA-CDI) and the number of positive C. difficile tests per 10,000 patient days as well as adherence to administration of Bio-K+ within 48 and 72 hours of antibiotic administration. Mixed-effects generalized linear models, adjusted for influenza admissions and facility characteristics, were used to evaluate the impact of the intervention on outcomes., Results: Overall adherence of Bio-K+ administration ranged from 76.9% to 84.6% when stratified by facility and periods. Rates of adherence to administration within 48 and 72 hours of antibiotic treatment were 60.2% -71.4% and 66.7%-75.8%, respectively. In the adjusted analysis, there was no change in HA-CDI (incidence rate ratio [IRR], 0.92; 95% confidence interval [CI], 0.68-1.23) or C. difficile positivity rate (IRR, 1.05; 95% CI, 0.89-1.24). Discharged patients may not have received a complete course of Bio-K+. Our hospitals had a low baseline incidence of HA-CDI. Patients who did not receive Bio-K+ may have differential risks of acquiring CDI, introducing selection bias., Conclusions: Hospitals considering probiotics as a primary prevention strategy should consider the baseline incidence of HA-CDI in their population and timing of probiotics relative to the start of antimicrobial administration.

Objective: Antimicrobial stewardship (AS) education initiatives for multidisciplinary teams are most successful when addressing psychosocial factors driving antimicrobial prescribing (AP) and when they address the needs of the team to allow for a tailored approach to their education., Design: We conducted a mixed-methods embedded study as a needs assessment, involving quantitative analysis of AS concerns observed by pharmacists through an audit while attending clinical team rounds, as well as qualitative semi-structured interviews based on the Theoretical Domain Framework (TDF) to identify psychosocial barriers and facilitators for antimicrobial prescribing for an inpatient general pediatric service. We analyzed the data using deductive and inductive methods by mapping the TDF to a model for social determinants of antimicrobial prescribing (SDAP) in pediatric inpatient health care teams., Setting: The Clinical Teaching Unit (CTU) and Pediatric Intensive Care Unit (PICU), at a tertiary care pediatric hospital in Canada., Participants: Interviews ( n = 23) with staff and resident physicians, nurse practitioners, and pharmacists., Results: Psychosocial facilitators and barriers for AS practice in the PICU and CTU which were identified included: collaboration, shared decision-making, locally accessible guidelines, and an overarching goal of doing right by the patient and feeling empowered as a prescriber . Some of the barriers identified included the norm of noninterference, professional comparisons, limited resources, feeling inadequately trained in AS, emotional prescribing, and a pejorative monitoring system ., Conclusions: Our findings identified barriers and facilitators to AS decisions on pediatric inpatient teams as well as actionable needs in psychosocial-based AS education., Competing Interests: The authors have no conflicts of interest to declare., (© The Author(s) 2024.)

Pulmonary embolism (PE) is a serious condition that presents a diagnostic challenge for which diagnostic errors often happen. The literature suggests that a gap remains between PE diagnostic guidelines and adherence in healthcare practice. While system-level decision support tools exist, the clinical impact of a human-centred design (HCD) approach of PE diagnostic tool design is unknown., Design: Before-after (with a preintervention period as non-concurrent control) design study., Setting: Inpatient units at two tertiary care hospitals., Participants: General internal medicine physicians and their patients who underwent PE workups., Intervention: After a 6-month preintervention period, a clinical decision support system (CDSS) for diagnosis of PE was deployed and evaluated over 6 months. A CDSS technical testing phase separated the two time periods., Measurements: PE workups were identified in both the preintervention and CDSS intervention phases, and data were collected from medical charts. Physician reviewers assessed workup summaries (blinded to the study period) to determine adherence to evidence-based recommendations. Adherence to recommendations was quantified with a score ranging from 0 to 1.0 (the primary study outcome). Diagnostic tests ordered for PE workups were the secondary outcomes of interest., Results: Overall adherence to diagnostic pathways was 0.63 in the CDSS intervention phase versus 0.60 in the preintervention phase (p=0.18), with fewer workups in the CDSS intervention phase having very low adherence scores. Further, adherence was significantly higher when PE workups included the Wells prediction rule (median adherence score=0.76 vs 0.59, p=0.002). This difference was even more pronounced when the analysis was limited to the CDSS intervention phase only (median adherence score=0.80 when Wells was used vs 0.60 when Wells was not used, p=0.001). For secondary outcomes, using both the D-dimer blood test (42.9% vs 55.7%, p=0.014) and CT pulmonary angiogram imaging (61.9% vs 75.4%, p=0.005) was lower during the CDSS intervention phase., Conclusion: A clinical decision support intervention with an HCD improves some aspects of the diagnostic decision, such as the selection of diagnostic tests and the use of the Wells probabilistic prediction rule for PE., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Patients with nosocomial acquisition of COVID-19 have poor outcomes but have not been included in therapeutic trials to date., Methods: A pragmatic open-label randomized controlled trial of anti-SARS-CoV-2 monoclonal antibodies (mAb) was performed in hospitalized patients with nosocomial COVID-19 infection in acute care hospitals spanning a provincial health care network. Participants within 5 days of first positive test or symptom onset were randomized to standard of care (SOC) plus a single dose intravenous mAb treatment (bamlanivimab or casirivimab/imdevimab) or SOC alone on a 2:1 basis. The primary study endpoint was the need for invasive mechanical ventilation (IMV) or inpatient mortality by day 60 after randomization., Results: Forty-six participants were enrolled from 13 hospitals between February 14 and October 8, 2021: 31 in the mAb and 15 in the SOC arm. IMV or inpatient mortality up to day 60 occurred in 4 (12.9%) participants in the mAb versus 3 in the SOC arm (20.0%), difference of -7.1% (95% CI -22.5 to 13.4, p = 0.67). The study was terminated early due to lack of equipoise as effectiveness of anti-viral therapies and mAb was published in similar high-risk patient populations., Conclusions: The trial was underpowered to detect meaningful differences given its early termination. The study does highlight the feasibility of undertaking trials in this patient population using a pragmatic approach allowing for trial participation and treatment access across a large health care network and may serve as a template for future designs., (© Association of Medical Microbiology and Infectious Disease Canada (AMMI Canada), 2023.)

Co-infections with SARS-CoV-2 remain relatively rare and there is limited published data on the consequences of these events. We present the case of a 26-year-old man with SARS-CoV-2 and human coronavirus OC43 who had a severe infection resulting in prolonged hospitalization. Consideration of co-infections should be considered in high-risk patients., Competing Interests: R Somayaji received clinical research grants from Cystic Fibrosis Foundation, Canadian Institutes of Health Research, Snyder Institute for Chronic Disease, and the Department of Surgery at the University of Calgary, received educational payments from Vertex Pharmaceuticals, and was a DSMB member on the Oncovir Phase II trial and an advisory board member for Vertex Pharmaceuticals. The other authors have nothing to disclose., (© Association of Medical Microbiology and Infectious Disease Canada (AMMI Canada), 2023.)

Background: Recent studies have demonstrated the effectiveness of nirmatrelvir-ritonavir in reducing the risk of progression to severe disease among outpatients with mild to moderate coronavirus disease 2019 (COVID-19); however, data are limited regarding the use and role of nirmatrelvir-ritonavir among hospitalized patients. This study describes the use and outcomes of nirmatrelvir-ritonavir among adults hospitalized with COVID-19 in a sentinel network of Canadian acute care hospitals during the Omicron variant phase of the pandemic., Methods: The Canadian Nosocomial Infection Surveillance Program conducts surveillance of hospitalized patients with COVID-19 in acute care hospitals across Canada. Demographic, clinical, treatment and 30-day outcome data were collected by chart review by trained infection control professionals using standardized questionnaires., Results: From January 1 to December 31, 2022, 13% (n=490/3,731) of adult patients (18 years of age and older) hospitalized with COVID-19 in 40 acute care hospitals received nirmatrelvir-ritonavir either at admission or during hospitalization. Most inpatients who received nirmatrelvir-ritonavir, 79% of whom were fully vaccinated, had at least one pre-existing comorbidity (97%) and were of advanced age (median=79 years). Few were admitted to an intensive care unit (2.3%) and among the 490 nirmatrelvir-ritonavir treated inpatients, there were 13 (2.7%) deaths attributable to COVID-19., Conclusion: These findings from a large sentinel network of Canadian acute-care hospitals suggest that nirmatrelvir-ritonavir is being used to treat adult COVID-19 patients at admission who are at risk of progression to severe disease or those who acquired COVID-19 in hospital. Additional research on the efficacy and indications for nirmatrelvir-ritonavir use in hospitalized patients is warranted to inform future policies and guidelines., Competing Interests: Competing interests A McGeer reported receiving research grants to the Sinai Health System from the COVID-19 Immunity Task Force, the Canadian Institutes of Health Research, Merck, Pfizer and Sanofi Pasteur; and receiving personal fees from AstraZeneca, GlaxoSmithKline, Janssen, Medicago, Merck, Moderna, Novavax, Pfizer and Sanofi Pasteur outside the submitted work. J Conly reported receiving research grants and funding from the Canadian Institutes for Health Research. He has participated in World Health Organization-funded studies outside of the submitted work. He was the primary local investigator for a study funded by Pfizer for which all funding was provided to the University of Calgary. Outside of the submitted work, he has received travel support from the Centers for Disease Control and Prevention and bioMérieux Canada. Outside of the submitted work, he is involved in multiple World Health Organization groups for which no funding is received. No other disclosures were reported.

Background: Staphylococcus aureus is a global pathogen that is frequently responsible for healthcare-associated infections, including surgical site infections (SSIs). Current infection prevention and control approaches may be limited, with S. aureus antibiotic resistance remaining problematic. Thus, a vaccine to prevent or reduce S. aureus infection is critically needed. We evaluated the efficacy and safety of an investigational 4-antigen S. aureus vaccine (SA4Ag) in adults undergoing elective open posterior spinal fusion procedures with multilevel instrumentation., Methods: In this multicenter, site-level, randomized, double-blind trial, patients aged 18-85 years received a single dose of SA4Ag or placebo 10-60 days before surgery. SA4Ag efficacy in preventing postoperative S. aureus bloodstream infection and/or deep incisional or organ/space SSIs was the primary end point. Safety evaluations included local reactions, systemic events, and adverse events (AEs). Immunogenicity and colonization were assessed., Results: Study enrollment was halted when a prespecified interim efficacy analysis met predefined futility criteria. SA4Ag showed no efficacy (0.0%) in preventing postoperative S. aureus infection (14 cases in each group through postoperative day 90), despite inducing robust functional immune responses to each antigen compared with placebo. Colonization rates across groups were similar through postoperative day 180. Local reactions and systemic events were mostly mild or moderate in severity, with AEs reported at similar frequencies across groups., Conclusions: In patients undergoing elective spinal fusion surgical procedures, SA4Ag was safe and well tolerated but, despite eliciting substantial antibody responses that blocked key S. aureus virulence mechanisms, was not efficacious in preventing S. aureus infection. Clinical Trials Registration. NCT02388165., Competing Interests: Potential conflicts of interest. H. H. is a consultant for Medtronic, DePuy, Nuvasive, and Orthofix; has obtained research support from Orthofix, Nuvasive, Medtronic, SKK, and Pfizer; has taught/spoken for Nuvasive, Medtronic, Orthofix, and Globus; has received payment for expert testimony from the Expert Institute; has participated on an advisory board for MTF; and reports stock or stock options with Nuvasive and 4Web. V. P. is a consultant for Medtronic; has obtained research support from Pfizer, Orthofix, Medicrea, Mainstay Medical, SI Bone, and Premia Spine; reports grants or contracts from Spinal Kinetics; reports consulting fees from DePuy Synthes, J&J SI-BONE, Mainstay Medical, Zimmer, Baxter, Stryker, and Aesculap; has filed multiple patents with the university office; and receives royalties from Stryker and Aesculap. H. K. has served as a consultant for Pfizer. D. N. is a consultant for Stryker. J. B., E. B., C. S., I. M., D. C., D. R., A. J., M. P., W. C. G., K. U. J., A. S. A., and A. G. are current employees of Pfizer and may hold stock or stock options. A. J. reports support for attending meetings as part of duties as a Pfizer employee and STRIVE team member. J. C. reports grants or contracts from the Canadian Institutes for Health Research and from Alberta Innovates; has received accommodations and airfare to attend and speak at a symposium from bioMerieux Canada; and is a member and chair of the World Health Organization (WHO) and a member of the WHO Health Emergencies Programme Ad-hoc COVID-19 IPC Guidance Development Group, both of which provide multidisciplinary advice to the WHO, for which no funding is received and from which no funding recommendations are made for any WHO contracts or grants; and works as an infectious diseases consultant at Alberta Health Services. K. J. reports consulting fees from and patents with Pfizer. M. W. reports royalties or licenses from Depuy-Synthes Spine; consulting fees from Depuy-Synthes Spine, Pacira, Stryker, NuVasive, Spineology, and Surgalign; and stock or stock options from Innovasive Surgical Devices, Kinesiomerics, and Medical Device Partners. All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2023. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Cerebrospinal fluid shunt-associated surgical site infection surveillance for 3 months compared to 12 months after surgery captures 83% of cases with no significant differences in patient characteristics, surgery types, or pathogens. A shorter 3-month follow-up can reduce resource use and allow for more timely reporting of healthcare-associated infection rates for hospitals.

Background: Antimicrobial resistance threatens the ability to successfully prevent and treat infections. While hospital benchmarks regarding antimicrobial use (AMU) have been well documented among adult populations, there is less information from among paediatric inpatients. This study presents benchmark rates of antimicrobial use (AMU) for paediatric inpatients in nine Canadian acute-care hospitals., Methods: Acute-care hospitals participating in the Canadian Nosocomial Infection Surveillance Program submitted annual AMU data from paediatric inpatients from 2017 and 2018. All systemic antimicrobials were included. Data were available for neonatal intensive care units (NICUs), pediatric ICUs (PICUs), and non-ICU wards. Data were analyzed using days of therapy (DOT) per 1000 patient days (DOT/1000pd)., Results: Nine hospitals provided paediatric AMU data. Data from seven NICU and PICU wards were included. Overall AMU was 481 (95% CI 409-554) DOT/1000pd. There was high variability in AMU between hospitals. AMU was higher on PICU wards (784 DOT/1000pd) than on non-ICU (494 DOT/1000pd) or NICU wards (333 DOT/1000pd). On non-ICU wards, the antimicrobials with the highest use were cefazolin (66 DOT/1000pd), ceftriaxone (59 DOT/1000pd) and piperacillin-tazobactam (48 DOT/1000pd). On PICU wards, the antimicrobials with the highest use were ceftriaxone (115 DOT/1000pd), piperacillin-tazobactam (115 DOT/1000pd), and cefazolin (111 DOT/1000pd). On NICU wards, the antimicrobials with the highest use were ampicillin (102 DOT/1000pd), gentamicin/tobramycin (78 DOT/1000pd), and cefotaxime (38 DOT/1000pd)., Conclusions: This study represents the largest collection of antimicrobial use data among hospitalized paediatric inpatients in Canada to date. In 2017/2018, overall AMU was 481 DOT/1000pd. National surveillance of AMU among paediatric inpatients is necessary for establishing benchmarks and informing antimicrobial stewardship efforts., (© 2023. The Author(s).)

Importance: Trends in COVID-19 severe outcomes have significant implications for the health care system and are key to informing public health measures. However, data summarizing trends in severe outcomes among patients hospitalized with COVID-19 in Canada are not well described., Objective: To describe trends in severe outcomes among patients hospitalized with COVID-19 during the first 2 years of the COVID-19 pandemic., Design, Setting, and Participants: Active prospective surveillance in this cohort study was conducted from March 15, 2020, to May 28, 2022, at a sentinel network of 155 acute care hospitals across Canada. Participants included adult (aged ≥18 years) and pediatric (aged 0-17 years) patients hospitalized with laboratory-confirmed COVID-19 at a Canadian Nosocomial Infection Surveillance Program (CNISP)-participating hospital., Exposures: COVID-19 waves, COVID-19 vaccination status, and age group., Main Outcomes and Measures: The CNISP collected weekly aggregate data on the following severe outcomes: hospitalization, admission to an intensive care unit (ICU), receipt of mechanical ventilation, receipt of extracorporeal membrane oxygenation, and all-cause in-hospital death., Results: Among 1 513 065 admissions, the proportion of adult (n = 51 679) and pediatric (n = 4035) patients hospitalized with laboratory-confirmed COVID-19 was highest in waves 5 and 6 of the pandemic compared with waves 1 to 4 (77.3 vs 24.7 per 1000 patient admissions). Despite this, the proportion of patients with positive test results for COVID-19 who were admitted to an ICU, received mechanical ventilation, received extracorporeal membrane oxygenation, and died were each significantly lower in waves 5 and 6 when compared with waves 1 through 4. Admission to the ICU and in-hospital all-cause death rates were significantly higher among those who were unvaccinated against COVID-19 when compared with those who were fully vaccinated (incidence rate ratio, 4.3 and 3.9, respectively) or fully vaccinated with an additional dose (incidence rate ratio, 12.2 and 15.1, respectively)., Conclusions and Relevance: The findings of this cohort study of patients hospitalized with laboratory-confirmed COVID-19 suggest that COVID-19 vaccination is important to reduce the burden on the Canadian health care system as well as severe outcomes associated with COVID-19.

Background: Science is becoming increasingly data intensive as digital innovations bring new capacity for continuous data generation and storage. This progress also brings challenges, as many scientific initiatives are challenged by the shear volumes of data produced. Here we present a case study of a data intensive randomized clinical trial assessing the utility of continuous pressure imaging (CPI) for reducing pressure injuries., Objective: To explore an approach to reducing the amount of CPI data required for analyses to a manageable size without loss of critical information using a nested subset of pressure data., Methods: Data from four enrolled study participants excluded from the analytical phase of the study were used to develop an approach to data reduction. A two-step data strategy was used. First, raw data were sampled at different frequencies (5, 30, 60, 120, and 240 s) to identify optimal measurement frequency. Second, similarity between adjacent frames was evaluated using correlation coefficients to identify position changes of enrolled study participants. Data strategy performance was evaluated through visual inspection using heat maps and time series plots., Results: A sampling frequency of every 60 s provided reasonable representation of changes in interface pressure over time. This approach translated to using only 1.7% of the collected data in analyses. In the second step it was found that 160 frames within 24 h represented the pressure states of study participants. In total, only 480 frames from the 72 h of collected data would be needed for analyses without loss of information. Only ~ 0.2% of the raw data collected would be required for assessment of the primary trial outcome., Conclusions: Data reduction is an important component of big data analytics. Our two-step strategy markedly reduced the amount of data required for analyses without loss of information. This data reduction strategy, if validated, could be used in other CPI and other settings where large amounts of both temporal and spatial data must be analysed., (© 2023. The Author(s).)

Background: Resources to improve antimicrobial stewardship (AS) are limited, but a telestewardship platform can enable capacity building and scalability. The Alberta Telestewardship Network (ATeleNet) was designed to focus on outreach across the province of Alberta, Canada, and facilitate AS activities., Methods: Outreach occurred virtually between pharmacists and physicians in hospital and long-term care settings throughout Alberta via secure, enterprise video conferencing software on both desktop and mobile devices. We used a quantitative questionnaire adapted from the telehealth usability questionnaire to capture the health provider's experience during each session. The questionnaire consisted of 39 questions, and a 5-point Likert scale was used to assess the degree of agreement and collate responses into a descriptive analysis., Results: A total of 33 pilot consultations were completed between July 6, 2020 and December 15, 2021. The majority (22, 85%) of respondents agreed that video conference-based virtual sessions are an acceptable means to provide health care and that they were able to express themselves effectively to other health care professionals (23, 88%). Respondents agreed the system was simple to use (23, 96%), and that they could become productive quickly using the system (23, 88%). Overall, 24 (92%) respondents were satisfied or very satisfied with the virtual care platform., Conclusions: We implemented and evaluated a telehealth consultation and collaborative care service between AS providers at multiple centres. AHS has since prioritized similar workflows, including access to specialists in acute care, as part of their virtual health strategy. Evaluation results will be shared with provincial stakeholders for further strategic planning and deployment., Competing Interests: H Hoang is a member and co-chair of the Covenant Health Antimicrobial Stewardship Program and member of the Alberta Health Services province-wide Antimicrobial Stewardship Committee; J Conly is a member and co-chair of the Alberta Health Services province-wide Antimicrobial Stewardship Committee, and has received grants from the Canadian Institutes for Health Research, Pfizer, and WHO, and a peer-reviewed research grant on acute and primary care preparedness for COVID-19 in Alberta, Canada. He is a primary local investigator for the STRIVE S. aureus vaccine randomized controlled trial in vertebral spinal surgery with instrumentation, for which all funding was provided only to the University of Calgary; he is a co-investigator on a WHO-funded study using integrated human factors and ethnography approaches to identify and scale innovative IPC guidance implementation supports in primary care with a focus on low-resource settings and using drone aerial systems to deliver medical supplies and personal protective equipment to remote First Nations communities during the COVID-19 pandemic. J Conly received accommodation and airfare from the CDC to attend a Think Thank Meeting in 2019. C Constantinescu and D Sabuda are members of the Alberta Health Services province-wide Antimicrobial Stewardship Committee. The other authors have nothing to disclose relevant to the contents of this manuscript., (© Association of Medical Microbiology and Infectious Disease Canada (AMMI Canada), 2023.)

Wastewater-based SARS-CoV-2 surveillance enables unbiased and comprehensive monitoring of defined sewersheds. We performed real-time monitoring of hospital wastewater that differentiated Delta and Omicron variants within total SARS-CoV-2-RNA, enabling correlation to COVID-19 cases from three tertiary-care facilities with >2100 inpatient beds in Calgary, Canada. RNA was extracted from hospital wastewater between August/2021 and January/2022, and SARS-CoV-2 quantified using RT-qPCR. Assays targeting R203M and R203K/G204R established the proportional abundance of Delta and Omicron, respectively. Total and variant-specific SARS-CoV-2 in wastewater was compared to data for variant specific COVID-19 hospitalizations, hospital-acquired infections, and outbreaks. Ninety-six percent (188/196) of wastewater samples were SARS-CoV-2 positive. Total SARS-CoV-2 RNA levels in wastewater increased in tandem with total prevalent cases (Delta plus Omicron). Variant-specific assessments showed this increase to be mainly driven by Omicron. Hospital-acquired cases of COVID-19 were associated with large spikes in wastewater SARS-CoV-2 and levels were significantly increased during outbreaks relative to nonoutbreak periods for total SARS-CoV2, Delta and Omicron. SARS-CoV-2 in hospital wastewater was significantly higher during the Omicron-wave irrespective of outbreaks. Wastewater-based monitoring of SARS-CoV-2 and its variants represents a novel tool for passive COVID-19 infection surveillance, case identification, containment, and potentially to mitigate viral spread in hospitals., (© 2022 The Authors. Journal of Medical Virology published by Wiley Periodicals LLC.)

Background: It is uncertain if medical masks offer similar protection against COVID-19 compared with N95 respirators., Objective: To determine whether medical masks are noninferior to N95 respirators to prevent COVID-19 in health care workers providing routine care., Design: Multicenter, randomized, noninferiority trial. (ClinicalTrials.gov: NCT04296643)., Setting: 29 health care facilities in Canada, Israel, Pakistan, and Egypt from 4 May 2020 to 29 March 2022., Participants: 1009 health care workers who provided direct care to patients with suspected or confirmed COVID-19., Intervention: Use of medical masks versus fit-tested N95 respirators for 10 weeks, plus universal masking, which was the policy implemented at each site., Measurements: The primary outcome was confirmed COVID-19 on reverse transcriptase polymerase chain reaction (RT-PCR) test., Results: In the intention-to-treat analysis, RT-PCR-confirmed COVID-19 occurred in 52 of 497 (10.46%) participants in the medical mask group versus 47 of 507 (9.27%) in the N95 respirator group (hazard ratio [HR], 1.14 [95% CI, 0.77 to 1.69]). An unplanned subgroup analysis by country found that in the medical mask group versus the N95 respirator group RT-PCR-confirmed COVID-19 occurred in 8 of 131 (6.11%) versus 3 of 135 (2.22%) in Canada (HR, 2.83 [CI, 0.75 to 10.72]), 6 of 17 (35.29%) versus 4 of 17 (23.53%) in Israel (HR, 1.54 [CI, 0.43 to 5.49]), 3 of 92 (3.26%) versus 2 of 94 (2.13%) in Pakistan (HR, 1.50 [CI, 0.25 to 8.98]), and 35 of 257 (13.62%) versus 38 of 261 (14.56%) in Egypt (HR, 0.95 [CI, 0.60 to 1.50]). There were 47 (10.8%) adverse events related to the intervention reported in the medical mask group and 59 (13.6%) in the N95 respirator group., Limitation: Potential acquisition of SARS-CoV-2 through household and community exposure, heterogeneity between countries, uncertainty in the estimates of effect, differences in self-reported adherence, differences in baseline antibodies, and between-country differences in circulating variants and vaccination., Conclusion: Among health care workers who provided routine care to patients with COVID-19, the overall estimates rule out a doubling in hazard of RT-PCR-confirmed COVID-19 for medical masks when compared with HRs of RT-PCR-confirmed COVID-19 for N95 respirators. The subgroup results varied by country, and the overall estimates may not be applicable to individual countries because of treatment effect heterogeneity., Primary Funding Source: Canadian Institutes of Health Research, World Health Organization, and Juravinski Research Institute.

Objectives: The Canadian Nosocomial Infection Surveillance Program conducted point-prevalence surveys in acute-care hospitals in 2002, 2009, and 2017 to identify trends in antimicrobial use., Methods: Eligible inpatients were identified from a 24-hour period in February of each survey year. Patients were eligible (1) if they were admitted for ≥48 hours or (2) if they had been admitted to the hospital within a month. Chart reviews were conducted. We calculated the prevalence of antimicrobial use as follows: patients receiving ≥1 antimicrobial during survey period per number of patients surveyed × 100%., Results: In each survey, 28-47 hospitals participated. In 2002, 2,460 (36.5%; 95% CI, 35.3%-37.6%) of 6,747 surveyed patients received ≥1 antimicrobial. In 2009, 3,566 (40.1%, 95% CI, 39.0%-41.1%) of 8,902 patients received ≥1 antimicrobial. In 2017, 3,936 (39.6%, 95% CI, 38.7%-40.6%) of 9,929 patients received ≥1 antimicrobial. Among patients who received ≥1 antimicrobial, penicillin use increased 36.8% between 2002 and 2017, and third-generation cephalosporin use increased from 13.9% to 18.1% ( P < .0001). Between 2002 and 2017, fluoroquinolone use decreased from 25.7% to 16.3% ( P < .0001) and clindamycin use decreased from 25.7% to 16.3% ( P < .0001) among patients who received ≥1 antimicrobial. Aminoglycoside use decreased from 8.8% to 2.4% ( P < .0001) and metronidazole use decreased from 18.1% to 9.4% ( P < .0001). Carbapenem use increased from 3.9% in 2002 to 6.1% in 2009 ( P < .0001) and increased by 4.8% between 2009 and 2017 ( P = .60)., Conclusions: The prevalence of antimicrobial use increased between 2002 and 2009 and then stabilized between 2009 and 2017. These data provide important information for antimicrobial stewardship programs.

Background: The role of remdesivir in the treatment of hospitalized patients with COVID-19 remains ill-defined. We conducted a cost-effectiveness analysis alongside the Canadian Treatments for COVID-19 (CATCO) open-label, randomized clinical trial evaluating remdesivir., Methods: Patients with COVID-19 in Canadian hospitals from Aug. 14, 2020, to Apr. 1, 2021, were randomly assigned to receive remdesivir plus usual care versus usual care alone. Taking a public health care payer's perspective, we collected in-hospital outcomes and health care resource utilization alongside estimated unit costs in 2020 Canadian dollars over a time horizon from randomization to hospital discharge or death. Data from 1281 adults admitted to 52 hospitals in 6 Canadian provinces were analyzed., Results: The total mean cost per patient was $37 918 (standard deviation [SD] $42 413; 95% confidence interval [CI] $34 617 to $41 220) for patients randomly assigned to the remdesivir group and $38 026 (SD $46 021; 95% CI $34 480 to $41 573) for patients receiving usual care (incremental cost -$108 [95% CI -$4953 to $4737], p > 0.9). The difference in proportions of in-hospital deaths between remdesivir and usual care groups was -3.9% (18.7% v. 22.6%, 95% CI -8.3% to 1.0%, p = 0.09). The difference in proportions of incident invasive mechanical ventilation events between groups was -7.0% (8.0% v. 15.0%, 95% CI -10.6% to -3.4%, p = 0.006), whereas the difference in proportions of total mechanical ventilation events between groups was -5.7% (16.4% v. 22.1%, 95% CI -10.0% to -1.4%, p = 0.01). Remdesivir was the dominant intervention (but only marginally less costly, with mildly lower mortality) with an incalculable incremental cost effectiveness ratio; we report results of incremental costs and incremental effects separately. For willingness-to-pay thresholds of $0, $20 000, $50 000 and $100 000 per death averted, a strategy using remdesivir was cost-effective in 60%, 67%, 74% and 79% of simulations, respectively. The remdesivir costs were the fifth highest cost driver, offset by shorter lengths of stay and less mechanical ventilation., Interpretation: From a health care payer perspective, treating patients hospitalized with COVID-19 with remdesivir and usual care appears to be preferrable to treating with usual care alone, albeit with marginal incremental cost and small clinical effects. The added cost of remdesivir was offset by shorter lengths of stay in the intensive care unit and less need for ventilation., Study Registration: ClinicalTrials. gov, no. NCT04330690., Competing Interests: Competing interests: Robert Fowler is the H. Barrie Fairley Professor of Critical Care Medicine at the University Health Network and the University of Toronto Interdepartmental Division of Critical Care Medicine. Robert Fowler declares a Canadian Institutes of Health Research (CIHR) operating grant. John Conly declares grants from the CIHR, Pfizer and the World Health Organization (WHO). He declares a peer-reviewed research grant on acute and primary care preparedness for COVID-19 in Alberta, Canada; he was a primary local investigator for the STRIVE Staphylococcus aureus vaccine randomized controlled trial in vertebral spinal surgery with instrumentation for which all funding was provided only to the University of Calgary; he was a co-investigator on a WHO-funded study using integrated human factors and ethnography approaches to identify and scale innovative infection prevention and control (IPC) guidance implementation supports in primary care with a focus on low-resource settings and using drone aerial systems to deliver medical supplies and personal protective equipment to remote First Nations communities during the COVID-19 pandemic. John Conly also reports receiving accommodations and airfare from the Centers for Disease Control and Prevention to attend a meeting in 2019. He is a member and chair of the WHO Infection Prevention and Control Research and Development Expert Group for COVID-19 and a member of the WHO Health Emergencies Programme Ad-hoc COVID-19 IPC Guidance Development Group, both of which provide multidisciplinary advice to the WHO, for which no funding is received and from which no funding recommendations are made for any WHO contracts or grants. He is also a member of the Cochrane Acute Respiratory Infections Group. Darrell Tan is supported by a Tier 2 Canada Research Chair in HIV Prevention and STI Research. Ryan Zarychanski reports grants from the CIHR, the Peter Munk Cardiac Centre, the Thistledown Foundation and the National Institutes of Health. He is a WHO thrombostasis technical advisory member. Ryan Zarychanski is the recipient of the Lyonel G. Israels Research Chair in Hematology at the University of Manitoba. Todd Lee reports a CATCO operating grant from the CIHR as a co–principal investigator and a co-investigator. He reports various operating grants from the CIHR, a technical development grant from the Centre for Aging + Brain Health Innovation and research salary support from the Fonds de recherche du Québec — Santé. He is the co-owner of a company that is bringing Med-Safer to market. Srinivas Murthy is the Innovative Medicines Canada and Health Research Foundation Chair in Pandemic Preparedness Research. Srinivas Murthy reports a grants from the CIHR and Health Research Foundation and Innovative Medicines Canada., (© 2022 CMA Impact Inc. or its licensors.)

Wastewater monitoring of SARS-CoV-2 enables early detection and monitoring of the COVID-19 disease burden in communities and can track specific variants of concern. We determined proportions of the Omicron and Delta variants across 30 municipalities covering >75% of the province of Alberta (population 4.5 million), Canada, during November 2021-January 2022. Larger cities Calgary and Edmonton exhibited more rapid emergence of Omicron than did smaller and more remote municipalities. Notable exceptions were Banff, a small international resort town, and Fort McMurray, a medium-sized northern community that has many workers who fly in and out regularly. The integrated wastewater signal revealed that the Omicron variant represented close to 100% of SARS-CoV-2 burden by late December, before the peak in newly diagnosed clinical cases throughout Alberta in mid-January. These findings demonstrate that wastewater monitoring offers early and reliable population-level results for establishing the extent and spread of SARS-CoV-2 variants.

Background: In many jurisdictions healthcare workers (HCWs) are using respirators for aerosol-generating medical procedures (AGMPs) performed on adult and pediatric populations with all suspect/confirmed viral respiratory infections (VRIs). This systematic review assessed the risk of VRIs to HCWs in the presence of AGMPs, the role respirators versus medical/surgical masks have on reducing that risk, and if the risk to HCWs during AGMPs differed when caring for adult or pediatric patient populations., Main Text: We searched MEDLINE, EMBASE, Cochrane Central, Cochrane SR, CINAHL, COVID-19 specific resources, and MedRxiv for English and French articles from database inception to September 9, 2021. Independent reviewers screened abstracts using pre-defined criteria, reviewed full-text articles, selected relevant studies, abstracted data, and conducted quality assessments of all studies using the ROBINS-I risk of bias tool. Disagreements were resolved by consensus. Thirty-eight studies were included; 23 studies on COVID-19, 10 on SARS, and 5 on MERS/ influenza/other respiratory viruses. Two of the 16 studies which assessed associations found that HCWs were 1.7 to 2.5 times more likely to contract COVID-19 after exposure to AGMPs vs. not exposed to AGMPs. Eight studies reported statistically significant associations for nine specific AGMPs and transmission of SARS to HCWS. Intubation was consistently associated with an increased risk of SARS. HCWs were more likely (OR 2.05, 95% CI 1.2-3.4) to contract human coronaviruses when exposed to an AGMP in one study. There were no reported associations between AGMP exposure and transmission of influenza or in a single study on MERS. There was limited evidence supporting the use of a respirator over a medical/surgical mask during an AGMP to reduce the risk of viral transmission. One study described outcomes of HCWs exposed to a pediatric patient during intubation., Conclusion: Exposure to an AGMP may increase the risk of transmission of COVID-19, SARS, and human coronaviruses to HCWs, however the evidence base is heterogenous and prone to confounding, particularly related to COVID-19. There continues to be a significant research gap in the epidemiology of the risk of VRIs among HCWs during AGMPs, particularly for pediatric patients. Further evidence is needed regarding what constitutes an AGMP., (© 2022. The Author(s).)

Objective: Ventriculoperitoneal (VP) shunt insertion and revision surgeries are some of the most common procedures that are performed by neurosurgeons. Shunt infections within the adult population are associated with significant morbidity and mortality and rates remain high. The objective of the current study was to use quality improvement (QI) methodology to create a standardized infection prevention bundle aimed at reducing the rate of shunt infections., Methods: A prospective, single-center, single-surgeon QI study was undertaken. Patients were included if they were 18 years of age or older and were undergoing a VP shunt insertion or revision. The primary outcome of the study was the development of a shunt-related surgical site infection, within 1 year of surgery, as defined according to the Canadian Nosocomial Infection Surveillance Program guidelines. There was no standardized protocol prior to July 2013. A bundle coined as the Calgary Adult Shunt Infection Prevention Protocol (CASIPP) was implemented on July 1, 2013, and updated on July 1, 2015, when 2% chlorhexidine gluconate in 70% isopropyl alcohol replaced povidone-iodine for preoperative skin antisepsis. Protocol compliance was regularly monitored using a standardized process. No antibiotic-impregnated catheters were used., Results: A total of 621 consecutive VP shunt insertions and revisions were included in the study. The rate of shunt infection was 5.8% during the period in which there was no standardized shunt protocol. After the implementation of the CASIPP the infection rate decreased to 4.0%, and after introduction of the chlorhexidine/alcohol skin antisepsis, the infection rate was 0% in 379 consecutive procedures (p < 0.0001). Multivariable logistic regression analysis demonstrated that the use of chlorhexidine/alcohol with CASIPP was associated with a significant reduction in the odds of developing a shunt infection (OR 0.032, 95% CI 0-0.19, p = 0.0005)., Conclusions: The implementation of a standardized shunt infection prevention bundle within the adult population, without the use of antibiotic-impregnated catheters, significantly reduced the rate of shunt infections which was sustained over many years. The use of 2% chlorhexidine gluconate in 70% isopropyl alcohol for preoperative antisepsis may have played a significant role. Multicenter studies should be completed to verify the effectiveness of the authors' protocol.

Background: Health care inequity in remote and rural Indigenous communities often involves difficulty accessing health care services and supplies. Remotely Piloted Aircraft Systems, or drones, offer a potentially cost-effective method for reducing inequity by removing geographic barriers, increasing timeliness, and improving accessibility of supplies, equipment, and remote care., Methods: We assessed the feasibility of drones for delivery of supplies, medical equipment, and medical treatment across multiple platforms, including drone fleet development and testing; payload system integration (custom fixed-mount, winch, and parachute); and medical delivery simulations (COVID-19 test kit delivery and return, delivery of personal protective equipment, and remote ultrasound delivery and testing)., Results: Drone operational development has led to a finalized, scalable fleet of small to large drones with functional standard operating procedures across a range of scenarios, and custom payload systems including a fixed-mount, winch-based and parachute-based system. Simulation scenarios were successful, with COVID-19 test swabs returned to the lab with no signal degradation and a remote ultrasound successfully delivered and remotely guided in the field., Discussion/conclusions: Drone-based medical delivery models offer an innovative approach to addressing longstanding issues of health care access and equity and are particularly relevant in the context of SARS-CoV-2., (Copyright © 2022. Published by Elsevier Inc.)

Systematic reviews of 591 primary studies of the modes of transmission for SARS-CoV-2 show significant methodological shortcomings and heterogeneity in the design, conduct, testing, and reporting of SARS-CoV-2 transmission. While this is partly understandable at the outset of a pandemic, evidence rules of proof for assessing the transmission of this virus are needed for present and future pandemics of viral respiratory pathogens. We review the history of causality assessment related to microbial etiologies with a focus on respiratory viruses and suggest a hierarchy of evidence to integrate clinical, epidemiologic, molecular, and laboratory perspectives on transmission. The hierarchy, if applied to future studies, should narrow the uncertainty over the twin concepts of causality and transmission of human respiratory viruses. We attempt to address the translational gap between the current research evidence and the assessment of causality in the transmission of respiratory viruses with a focus on SARS-CoV-2. Experimentation, consistency, and independent replication of research alongside our proposed framework provide a chain of evidence that can reduce the uncertainty over the transmission of respiratory viruses and increase the level of confidence in specific modes of transmission, informing the measures that should be undertaken to prevent transmission.

Background: Multi-drug-resistant organisms (MDROs) (meticillin-resistant Staphylococcus aureus, vancomycin-resistant enterococcus, MDR Acinetobacter spp., extended-spectrum beta-lactamase-producing Gram-negative organisms), Clostridioides difficile, viral respiratory pathogens and healthcare-associated infections (HAIs) are major concerns in medical facilities., Aims: To assess environmental service workers' (ESWs) training, workload, numbers of surfaces and pieces of medical equipment cleaned per shift, how long they worked on each surface, how they cleaned, supervision, MDRO and HAI status, and measurement of effectiveness in reducing MDROs and HAIs in patients and on surfaces., Methods: CINAHL, Cochrane CENTRAL Register of Controlled Trials, EMBASE, Medline and Scopus were searched from inception to 28 th June 2021 (no language/date limits). Searches combined terms from three themes: (a) hospitals and acute/long-term care facilities (e.g. assisted living, long-term care facilities, nursing homes); (b) disinfectants (e.g. antisepsis, bleach, cleaning, copper plating of surfaces and copper impregnation of textiles, disinfection, decontamination, hydrogen peroxide, quaternary ammonium disinfectants, and ultraviolet rays); and (c) randomized controlled trials (RCTs)., Findings and Conclusions: Fourteen cluster RCTs provided data on a series of interventions. Ten trials focused on reducing patient infections from MDROs/HAIs, and four found significant reductions in patient infection rates with strategies including bleach, quaternary ammonium detergents, ultraviolet light and hydrogen peroxide vapour. Minimal information was provided on ESW numbers, MDRO/HAI status, workload, numbers of surfaces and objects cleaned per shift, and effects of training on improving effectiveness. The findings suggest that there is a need for detailed evaluations of the effects of training and disinfection activities for individuals and teams of ESWs., (Copyright © 2022 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

Background: Multiply drug-resistant organisms (MDROs) in hospitals and long-term care facilities (LTCFs) of particular concern include meticillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococcus, multidrug-resistant Acinetobacter species, and extended-spectrum β-lactamase-producing organisms. Respiratory viruses include influenza and SARS-CoV-2., Aim: To assess effectiveness of cleaning and disinfecting surfaces in hospitals and LTCFs., Methods: CINAHL, Cochrane CENTRAL Register of Controlled Trials, Embase, Medline, and Scopus searched inception to June 28 th , 2021, no language restrictions, for randomized controlled trials (RCTs), cleaning, disinfection, hospitals, LTCFs. Abstracts and titles were assessed and data abstracted independently by two authors., Findings: Of 14 cluster (c)-RCTs in hospitals and LTCFs, interventions in ten were focused on reducing patient infections of four MDROs and/or healthcare-associated infections (HAIs). In four c-RCTs patient MDRO and/or HAI rates were significantly reduced with cleaning and disinfection strategies including bleach-, quaternary ammonium detergent-, ultraviolet irradiation-, hydrogen peroxide vapour- and copper-treated surfaces or fabrics. Of three c-RCTs focused on reducing MRSA rates, one had significant results and one on Clostridioides difficile had no significant results. Heterogeneity of populations, methods, outcomes and data reporting precluded meta-analysis. Overall risk of bias assessment was low but high for allocation concealment, and GRADE assessment was low risk. No study assessed biofilms., Conclusion: Ten c-RCTs focused on reducing multiple MDROs and/or HAIs and four had significant reductions. Three c-RCTs reported only patient MRSA colonization rates (one significant reductions), and one focused on C. difficile (no significant differences). Standardized primary and secondary outcomes are required for future c-RCTs including detailed biofilm cleaning/disinfection interventions., (Copyright © 2021 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

Background: The role of remdesivir in the treatment of patients in hospital with COVID-19 remains ill defined in a global context. The World Health Organization Solidarity randomized controlled trial (RCT) evaluated remdesivir in patients across many countries, with Canada enrolling patients using an expanded data collection format in the Canadian Treatments for COVID-19 (CATCO) trial. We report on the Canadian findings, with additional demographics, characteristics and clinical outcomes, to explore the potential for differential effects across different health care systems., Methods: We performed an open-label, pragmatic RCT in Canadian hospitals, in conjunction with the Solidarity trial. We randomized patients to 10 days of remdesivir (200 mg intravenously [IV] on day 0, followed by 100 mg IV daily), plus standard care, or standard care alone. The primary outcome was in-hospital mortality. Secondary outcomes included changes in clinical severity, oxygen- and ventilator-free days (at 28 d), incidence of new oxygen or mechanical ventilation use, duration of hospital stay, and adverse event rates. We performed a priori subgroup analyses according to duration of symptoms before enrolment, age, sex and severity of symptoms on presentation., Results: Across 52 Canadian hospitals, we randomized 1282 patients between Aug. 14, 2020, and Apr. 1, 2021, to remdesivir ( n = 634) or standard of care ( n = 648). Of these, 15 withdrew consent or were still in hospital, for a total sample of 1267 patients. Among patients assigned to receive remdesivir, in-hospital mortality was 18.7%, compared with 22.6% in the standard-of-care arm (relative risk [RR] 0.83 (95% confidence interval [CI] 0.67 to 1.03), and 60-day mortality was 24.8% and 28.2%, respectively (95% CI 0.72 to 1.07). For patients not mechanically ventilated at baseline, the need for mechanical ventilation was 8.0% in those assigned remdesivir, and 15.0% in those receiving standard of care (RR 0.53, 95% CI 0.38 to 0.75). Mean oxygen-free and ventilator-free days at day 28 were 15.9 (± standard deviation [SD] 10.5) and 21.4 (± SD 11.3) in those receiving remdesivir and 14.2 (± SD 11) and 19.5 (± SD 12.3) in those receiving standard of care ( p = 0.006 and 0.007, respectively). There was no difference in safety events of new dialysis, change in creatinine, or new hepatic dysfunction between the 2 groups., Interpretation: Remdesivir, when compared with standard of care, has a modest but significant effect on outcomes important to patients and health systems, such as the need for mechanical ventilation. Trial registration : ClinicalTrials.gov, no. NCT04330690., Competing Interests: Competing interests: Alexandra Binnie reports receiving research grants from the Canadian Institutes of Health Research (CIHR) and the Physicians Services Incorporated Foundation. Sergio Borgia reports receiving honoraria from Gilead Sciences and GSK. Yiorgos Alexandros Cavayas reports receiving a grant from CIHR. Matthew Cheng reports receiving grants from the McGill Interdisciplinary Initiative in Infection and Immunity and from CIHR, during the conduct of the study (payments made to the institution). Dr. Cheng also reports receiving personal fees from AstraZeneca, outside the submitted work; and from Nplex Biosciences and GEn1E lifesciences (in the form of stock options for being a member of the scientific advisory board) outside the submitted work. Dr. Cheng co-founded Kanvas Biosicences and owns equity in the company, and reports 3 patents pending. John Conly reports receiving grants from CIHR, Pfizer, the World Health Organization (WHO), Sunnybrook Research Institute, University of Calgary, and the Calgary Health Foundation. Dr. Conly also reports receiving support to attend the Think Tank Meeting 2019. Dr. Conly is a member and Chair of the WHO Infection Prevention and Control Research and Development Expert Group for COVID-19, a member of the WHO Health Emergencies Programme (WHE) Ad-hoc COVID-19 IPC Guidance Development Group, and a member of the Cochrane Acute Respiratory Infections Group. Madeleine Durand reports receiving grants from CIHR and the Fonds Recherche du Québec–Santé (FRQS). Rob Fowler reports receiving a grant from CIHR for the CATCO trial and is the H. Barrie Fairley Professor of Critical Care at the University Health Network. Michael Fralick reports receiving multiple grants from CIHR and support from grants from the Canadian military for clinical trials to identify treatments for COVID-19 (payments made to institution). Dr. Fralick is a paid consultant for a start-up company called Proof DiagnosticsDx, which has created a point-of-care testing device using CRISPR for COVID-19. Holly Hoang reports receiving payment from CATCO Sunnybrook to fund research assistant (payment made to institution) and a research grant from Covenant Health Research Centre. Marina Klein reports receiving grants from Gilead, ViiV Healthcare, Merck and AbbVie for investigator-initiated studies, and consulting fees from Gilead, ViiV Healthcare, Merck and AbbVie, all outside the submitted work. Todd Lee reports receiving operating grants from CIHR and McGill Interdisciplinary Initiative in Infection and Immunity (MI4), and research salary support from FRQS. Alexandra Lostun reports receiving per-case funding to cover the costs of enrolling patients (paid to institution, North York General Hospital). François Carrier reports receiving grants from the Instituts de recherche en santé du Canada and the Canadian Donation and Transplantation Research Program, and a grant and salary support from FRQS. Marlee McGuinty reports receiving speaking fees from Merck. Srinivas Murthy reports receiving a grant from CIHR, during the conduct of the study, and is the Health Research Foundation and Innovative Medicines Canada Chair in Pandemic Preparedness Research. Conar O’Neil reports receiving conference sponsorship from Gilead Sciences, and is a member of a Gilead Sciences advisory board. Jesse Papenburg reports receiving a grant from CIHR, during the conduct of the study, as well as research grants and contracts from AbbVie and research contracts (site investigator for clinical trial) from MedImmune, Merck and Sanofi Pasteur. Dr. Papenburg has received consulting fees from Merck for an ad hoc advisory board meeting, and honoraria for presentations from Seegene, AbbVie and AstraZeneca. Dr. Papenburg is also a voting member of the National Advisory Committee on Immunization. Ken Kuljit S. Parhar reports receiving a CIHR project grant, Alberta Innovates grant and Alberta Health Innovation Implementation and Spread grant (all paid to institution). Seema Nair Parvathy reports receiving funding from St. Joseph’s Health Care Foundation and London Health Sciences Foundation. Moira Rushton-Marovac reports receiving advisory board honoraria from Gilead. Marina Salvadori reports being an employee of the Public Health Agency of Canada. Makeda Semret reports receiving support from the McGill MI4 for the clinical research platform through which CATCO was supported at the McGill University Health Centre. Ameeta Singh reports receiving consulting fees from Gilead for membership of an advisory board. Ranjani Somayaji reports receiving contract research funding from Sunnybrook Research Institute, University of Calgary and Calgary Health Foundation, and clinical research funding from CIHR and the Cystic Fibrosis Foundation. Dr. Somayaji also reports participation on an oncovir data monitoring safety board. Darrell Tan reports receiving grants from AbbVie (in-kind drug only) and Gilead (in-kind drug and grants to institution), and a contract between GSK and the institution for clinical trials. Alain Tremblay reports receiving contract research funding from the Sunnybrook Research Institute, and grants for COVID-19 clinical trials from the University of Calgary and Calgary Health Foundation. Alexis Turgeon reports receiving a grant from CIHR. Jason Weatherald reports receiving grants (paid to institution) and consulting fees (paid to Dr. Weatherald) from Janssen and Actelion, as well as honoraria and travel support from Janssen. Dr. Weatherald has served on advisory boards for Janssen and Acceleron (paid) and on a Data Safety Monitoring Board for Université Laval (unpaid). Dr. Weatherald also reports membership of the Medical Advisory Committee of the Pulmonary Hypertension Association of Canada, and is a shareholder of Precision Lung Consultants and Diagnostics. Cedric Yansouni reports receiving grants from FRQS and consulting fees from Medicago Inc. Dr. Yansouni also reports participation in a Medicago Inc. Independent Data Monitoring Committee and held the role of scientific advisor for the COVID-19 Immunity Task Force. No other competing interests were declared., (© 2022 CMA Impact Inc. or its licensors.)

Background: Few studies have assessed the relationship between poverty and the risk of infection with antimicrobial resistant organisms (AROs). We sought to identify, appraise, and synthesize the available published Canadian literature that analyzes living in poverty and risk of AROs., Methods: A structured narrative review methodology was used, including a systematic search of three databases: MedLINE, EMBASE and Web of Science for articles pertaining to poverty, and infection with AROs in Canada between 1990 and 2020. Poverty was broadly defined to include economic measures and associated social determinants of health. Based on inclusion and exclusion criteria, there were 889 initial articles, and 43 included in the final review. The final articles were extracted using a standard format and appraised using the Joanna Briggs Institute Levels of Evidence framework., Results: Of 43 studies, 15 (35%) related to methicillin-resistant Staphylococcus aureus (MRSA). One study found a 73% risk reduction (RR 0.27, 95%CI 0.19-0.39, p =  < 0.0001) in community-acquired MRSA (CA-MRSA) infection for each $100,000 income increase. Results pertaining to homelessness and MRSA suggested transmission was related to patterns of frequent drug use, skin-to-skin contact and sexual contact more than shelter contact. Indigenous persons have high rates of CA-MRSA, with more rooms in the house being a significant protective factor (OR 0.86, p = 0.023). One study found household income over $60,000 (OR 0.83, p = 0.039) in univariate analysis and higher maternal education (OR 0.76, 95%CI 0.63-0.92, p = 0.005) in multivariate analysis were protective for otitis media due to an ARO among children. Twenty of 43 (46.5%) articles pertained to tuberculosis (TB). Foreign-born persons were four times more likely to have resistant TB compared to Canadian-born persons. None of the 20 studies used income in their analyses., Conclusions: There is an association between higher income and protection from CA-MRSA. Mixed results exist regarding the impact of homelessness and MRSA, demonstrating a nuanced relationship with behavioural risk factors. Higher income and maternal education were associated with reduced ARO-associated acute otitis media in children in one study. We do not have a robust understanding of the social measures of marginalization related to being foreign-born that contribute to higher rates of resistant TB infection., (© 2022. The Author(s).)

Background: Patient-level surveillance of antimicrobial use (AMU) in Canadian hospitals empowers the reduction of inappropriate AMU and was piloted in 2017 among 14 hospitals in Canada. We aimed to describe AMU on the basis of patient-level data in Canadian hospitals in 2018 in terms of antimicrobial prescribing prevalence and proportions, antimicrobial indications, and agent selection in medical, surgical and intensive care wards., Methods: Canadian adult, pediatric and neonatal hospitals were invited to participate in the standardized web-based cross-sectional Global Point Prevalence Survey of Antimicrobial Consumption and Resistance (Global-PPS) conducted in 2018. An identified site administrator assigned all wards admitting inpatients to specific surveyors. A physician, pharmacist or nurse with infectious disease training performed the survey. The primary outcomes were point prevalence rates for AMU over the study period regarding prescriptions, indications and agent selection in medical, surgical and intensive care wards. The secondary outcomes were AMU for resistant organisms and practice appropriateness evaluated on the basis of quality indicators. Antimicrobial consumption is presented in terms of prevalence and proportions., Results: Forty-seven of 118 (39.8%) hospitals participated in the survey; 9 hospitals were primary care centres, 15 were secondary care centres and 23 were tertiary or specialized care centres. Of 13 272 patients included, 33.5% ( n = 4447) received a total of 6525 antimicrobials. Overall, 74.1% (4832/6525) of antimicrobials were for therapeutic use, 12.6% ( n = 825) were for medical prophylaxis, 8.9% ( n = 578) were for surgical prophylaxis, 2.2% ( n = 143) were for other use and 2.3% ( n = 147) were for unidentified reasons. A diagnosis or indication was documented in the patient's file at the initiation for 87.3% ( n = 5699) of antimicrobials; 62.9% ( n = 4106) of antimicrobials had a stop or review date; and 72.0% ( n = 4697) of prescriptions were guided by local guidelines., Interpretation: Overall, three-quarters of AMU was for therapeutic use across participating hospitals. Canadian hospitals should be further incentivized to create and adapt local guidelines on the basis of recent antimicrobial resistance data., Competing Interests: Competing interests: Daniel Thirion has shares in Lumed. No other competing interests were declared., (© 2021 CMA Joule Inc. or its licensors.)

The COVID-19 pandemic exposed primary care (PC), and policies aimed at integrating it into provincial health systems, to a "shock test." This paper draws on documentary analysis and qualitative interviews with PC and health system stakeholders to examine shifts in Alberta's pre-pandemic PC integration model during the first nine months of the pandemic. We begin with an account of three elements of the province's pre-pandemic model: finance, health authority activity and community activity. We describe these elements as they shifted, focusing on two indicators of change: novel virtual care billing codes and personal protective equipment (PPE) distribution channels. We draw out policy planning lessons for improving PC integration under normal and future pandemic conditions, namely, by facilitating rapid updates of virtual care billing codes, analyses of the impact of care delivery and backstopping of PPE markets and supply chains for PC., (Copyright © 2021 Longwoods Publishing.)

The COVID-19 pandemic has tested the resilience of health systems broadly and primary care (PC) specifically. This paper begins by distinguishing the technical and political aspects of resilience and then draws on a documentary analysis and qualitative interviews with health system and PC stakeholders to examine competing resilience-focused responses to the pandemic in Alberta, Canada. We describe the pre-existing linkages between the province's central service delivery agency and its independent PC clinics. Together, these central and independent elements make up Alberta's broader health system, with the focus of this paper being on PC's particular vision of how resilience ought to be achieved. We describe two specific, pandemic-affected areas of activity by showing how competing visions of resilience emerged in the central service delivery agency and independent PC responses as they met at the system's points of linkage. At the first point of linkage, we describe the centralized activation of an incident management system and the replies made by independent PC stakeholders. At the second point of linkage, we describe central efforts to disseminate infection prevention and control guidance to PC clinics and the improvisational efforts of staff at those independent clinics to operationalize the guidance and ensure continuity of operations. We identify gaps between the resilience visions of the central agency and independent PC, drawing broadly applicable policy lessons for improving responses in present and future public health emergencies. Finding ways to include PC in centralized resilience policy planning is a priority., (Copyright © 2021 Longwoods Publishing.)

Background: The COVID-19 pandemic has led to personal protective equipment (PPE) supply concerns on a global scale. While efforts to increase production are underway in many jurisdictions, demand may yet outstrip supply leading to PPE shortages, particularly in low resource settings. PPE is critically important for the safety of healthcare workers (HCW) and patients and to reduce viral transmission within healthcare facilities. A structured narrative review was completed to identify methods for extending the use of available PPE as well as decontamination and reuse., Methods: Database searches were conducted in MEDLINE and EMBASE for any available original research or review articles detailing guidelines for the safe extended use of PPE, and/or PPE decontamination and reuse protocols prior to September 28, 2020. Grey literature in addition to key websites from the Centers for Disease Control and Prevention (CDC), World Health Organization (WHO), Infection Prevention Association of Canada (IPAC), and the National Health Service (NHS) was also reviewed., Results: Extended use guidelines support co-locating patients with confirmed COVID-19 within specific areas of healthcare facilities to enable the use of PPE between multiple patients, and reduce PPE requirements outside these areas. Decontamination strategies for N95 respirators and face shields range from individual HCWs using conventional ovens and microwave steam bags at home, to large-scale centralized decontamination using autoclave machines, ultraviolet germicidal irradiation, hydrogen peroxide vapors, or peracetic acid dry fogging systems. Specific protocols for such strategies have been recommended by the US CDC and WHO and are being implemented by multiple institutions across North America. Further studies are underway testing decontamination strategies that have been reported to be effective at inactivating coronavirus and influenza, and on SARs-CoV-2 specifically., Conclusions: This narrative review summarizes current extended use guidelines and decontamination protocols specific to COVID-19. Preserving PPE through the implementation of such strategies could help to mitigate shortages in PPE supply, and enable healthcare facilities in low resource settings to continue to operate safely for the remainder of the COVID-19 pandemic., (© 2021 The Authors.)

Introduction: The COVID-19 pandemic prompted widescale use of clinical simulations to improve procedures and practices. We outline our deployment of a virtual tabletop simulation (TTS) method in primary care (PC) clinics across Alberta, Canada. We summarise the quality and safety improvements from this method and report end users' perspectives on key elements., Methods: Our virtual TTS used teleconferencing software alongside digital whiteboards to walk clinic stakeholders through patient scenarios. Participants reviewed and rehearsed their workflows and care practices. The goal was for staff to take ownership over gaps and codesigned solutions. After simulation sessions, follow-up interviews were conducted to collect feedback., Results: These sessions helped PC staff identify and codesign solutions for clinical hazards and threats. These included the flow of patients through clinics, communications, redesignation of physical spaces, and adaptation of guidance for cleaning and personal protective equipment use. End users reported sessions provided neutral spaces to discuss practice changes and built confidence in delivering safe care during the pandemic., Discussion: TTS has not been extensively deployed to improve clinical practice in outpatient environments. We show how virtual TTS can bridge gaps between knowledge and practice by offering a guided space to rehearse clinical changes. We show that virtual TTS can be used in multiple contexts to help identify hazards, improve safety and build confidence in professional teams adapting to rapid changes in both policies and practices. While our sessions were conducted in Alberta, our results suggest this method may be deployed in other contexts, including low-resource settings., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Objective: Surgical site infections (SSIs) are a serious and costly post-op complication. Generating SSI rates often requires labor-intensive methods, but increasing numbers of publications reported SSI rates using administrative data., Methods: Index laminectomy and spinal fusion procedures were identified using Canadian Classification of Health Interventions (CCI) procedure codes for inpatients and outpatients in the province of Alberta, Canada between 2008 and 2015. SSIs occurring in the year postsurgery were identified using the International Classification of Diseases, 10th Revision, Canada (ICD-10-CA) diagnosis and CCI procedure codes indicative of post-op infection. Rates of SSIs and case characteristics were reported., Results: Over the 8-year study period, 21,222 index spinal procedures were identified of which 12,027 (56.7%) were laminectomy procedures, with 322 SSIs identified, an SSI rate of 2.7 per 100 procedures. Of the 9,195 (43.3%) fusion procedures, 298 were identified as an SSI, an SSI rate of 3.2 per 100 procedures. This study found SSI rates increased from 2008 and 2015, and rates were the highest in the 0-18 year age group., Conclusions: The rates reported in this study were similar to published SSI rates using traditional surveillance methods, suggesting administrative data may be a viable method for reporting SSI rates following spinal procedures. Further work is needed to validate SSIs identified using administrative data by comparing to traditional surveillance., (Copyright © 2020 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.)

USA300 is a predominant and highly virulent community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) strain that is a leading cause of skin and soft tissue infections. We established a murine intradermal infection model capable of demonstrating dermatopathological differences between USA300 and other MRSA strains. In this model, USA300 induced dermonecrosis, uniformly presenting as extensive open lesions with a histologically documented profound inflammatory cell infiltrate extending below the subcutis. In contrast, USA400 and a colonizing control strain M92 caused only localized non-ulcerated skin infections associated with a mild focal inflammatory infiltrate. It was also determined that the dermonecrosis induced by USA300 was associated with significantly increased neutrophil recruitment, inhibition of an antibacterial response, and increased production of cytokines/chemokines associated with disease severity. These results suggest that induction of severe skin lesions by USA300 is related to over-activation of neutrophils, inhibition of host antibacterial responses, and selective alteration of host cytokine/chemokine profiles.

Background: In response to the Coronavirus disease-19 (COVID-19) pandemic, in-patient units in hospitals around the world have altered their patient care routines and Infection Prevention and Control (IPC) practices. Our interdisciplinary team of applied Human Factors (HF), ethnography, and IPC experts assisted one Unit, normally serving general surgical and orthopedic patients, as it rapidly converted to deliver COVID-19-specific care. This paper describes the conversion experience of the Unit, and outlines broader lessons for other acute care teams faced with similar issues., Methods: We deployed walkthroughs, simulations, and ethnography to identify important safety gaps in care delivery processes on the Unit. These interventions were undertaken using interdisciplinary theories of implementation that combined systems-level HF perspectives, ethnographic approaches, and individual-level IPC perspectives. Timely recommendations were developed and delivered to Unit staff for feedback and implementation., Results: We describe three interventions on the Unit: 1) the de-cluttering and re-organization of personal protective equipment (PPE); 2) the reconfiguring of designated 'dirty' tray tables and supplies; and 3) the redesign of handling pathways for 'dirty' linens and laundry. Each of these interventions was implemented to varying degrees, but all contributed to discussions of safety and IPC implementation that extended beyond the Unit and into the operations of the broader hospital., Conclusions: Leveraging our team's interdisciplinary expertise and blended approaches to implementation, the interventions assisted in the Unit's rapid conversion towards providing COVID-19-specific care. The deployment and implementation of the interventions highlight the potential of collaboration between HF, ethnography, and IPC experts to support frontline healthcare delivery under pandemic conditions in an effort to minimize nosocomial transmission potential in the acute healthcare setting., Competing Interests: The authors have declared that no competing interests exist.

Competing Interests: Intérêts concurrents : Henry T. Stelfox a reçu du financement d’une Bourse salariale de clinicien-chercheur intégré des Instituts de recherche en santé du Canada (IRSC). John Conly a reçu des subventions des IRSC pour des recherches sur les mesures de préparation à la COVID-19 dans les milieux de soins actifs et primaires en Alberta (Canada), et il était le chercheur local principal dans le cadre d’une étude sur un vaccin contre Staphylococcus aureus financée par Pfizer, pour laquelle tout le financement a été versé seulement à l’Université de Calgary. Il a également reçu du financement des Centres for Disease Control and Prevention pour assister à une réunion d’un comité de réflexion sur le contrôle des infections. Aucun autre intérêt concurrent déclaré. Cet article a été révisé par des pairs.

Background: Our laboratory uses matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI) and the VITEK 2 system (DV2) directly from positive blood cultures (BC) for organism identification (ID) and antimicrobial susceptibility testing (AST). Our objective was to compare direct MALDI-DV2 with a commercial BC ID-AST platform, the Accelerate Pheno system (AXDX), in the ID-AST of clinical and seeded BC positive for gram-negative bacilli (GNB)., Methods: BC positive for GNB were collected over a 3-mo period and tested using AXDX and direct MALDI-DV2 and compared with conventional methods. A subset of sterile BC were seeded with multi-drug-resistant GNB., Results: Twenty-nine clinical samples and 35 seeded samples were analyzed. Direct MALDI had a higher ID failure rate (31.0%) than AXDX (3.4%; p < 0.001). Time to ID-AST was 1.5-6.9 h, 5.8-16.5 h, and 21.6-33.0 h for AXDX, direct MALDI-DV2, and conventional methods, respectively ( p < 0.001). For clinical samples, AXDX and DV2 had essential agreement (EA) or categorical agreement (CA) of more than 96%. For seeded samples, AXDX had EA, CA, VME, ME, and minor error (mE) of 93.2%, 89.0%, 2.2%, 0%, and 9.2%, respectively. AXDX had a large number of non-reports (6.1%) stemming from meropenem testing. DV2 had EA, CA, VME, ME, and mE of 97.5%, 94.7%, 1.3%, 0%, and 4.1%, respectively., Conclusions: Direct MALDI-DV2 and AXDX both had high agreement for clinical samples, but direct MALDI-DV2 had higher agreement when challenged with MDR GNB., Competing Interests: The use of the Accelerate Pheno™ system and its kits was provided by Accelerate Diagnostics, Inc. The authors acted independently with respect to study design, data collection, data analysis, and the preparation and contents of this publication., (Copyright © 2020, Association of Medical Microbiology and Infectious Disease Canada (AMMI Canada).)

An amendment to this paper has been published and can be accessed via the original article.

Rates of vancomycin-resistant enterococci bloodstream infections have remained relatively low in Canada. We recently observed an increase of 113% in these infections rates, which coincided with emergence of Enterococcus faecium pstS-null sequence type 1478. The proportion of this sequence type increased from 2.7% to 38.7% for all tested isolates from 2013-2018.