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Clostridioides difficile infection (CDI) contributes the global threats of drug resistant infections, healthcare acquired infections and antimicrobial resistance. Yet CDI knowledge among healthcare providers in low-resource settings is limited and CDI testing, treatment, and infection prevention measures are often delayed.to develop a CDI intervention informed by the local context within South African public district level hospitals, and analyze the CDI intervention and implementation process.A CDI checklist intervention was designed and implemented at three district level hospitals in the Western Cape, South Africa that volunteered to participate. Data collection included a retrospective medical records review of patients hospitalized with C. difficile test orders during the 90 days post-implementation. Patient outcomes and checklist components (e.g. antibiotics) were collected. Qualitative interviews (n = 14) and focus groups (n = 6) were conducted with healthcare providers on-site. The Consolidated Framework for Implementation Research (CFIR) and the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS) were applied to collected data and observations in order to identify drivers and barriers to implementation and understand differences in uptake.One of the three hospitals displayed high intervention uptake. Highly relevant CFIR constructs linked to intervention uptake included tension for change, strong peer intervention champions, champions in influential leadership positions, and the intervention's simplicity (CFIR construct: complexity). Tension for change, a recognized need to improve CDI identification and treatment, at the high uptake hospital was also supported by an academic partnership for antimicrobial stewardship.This research provides a straight-forward health systems strengthening intervention for CDI that is both needed and uncomplicated, in an understudied low resource setting. Intervention uptake was highest in the hospital with tension for change, influential champions, and existing academic partnerships. Implementation in settings with fewer academic connections requires further testing of collaborative implementation strategies and proactive adaptations.

A survey of Veterans' Affairs Medical Centers on control of carbapenem-resistant Enterobacteriaceae (CRE) and carbapenem-producing CRE (CP-CRE) demonstrated that most facilities use VA guidelines but few screen for CRE/CP-CRE colonization regularly or regularly communicate CRE/CP-CRE status at patient transfer. Most respondents were knowledgeable about CRE guidelines but cited lack of adequate resources.

Guidelines for treatment of resistant Acinetobacter baumannii (AB) are limited, leaving a knowledge gap in best practices for treatment. This study described treatments and outcomes of extensively-drug resistant (XDR) AB.Retrospective cohort study including patients with XDRAB (non-susceptible to at least 1 agent in all but 2 or fewer classes) and antibiotic treatment between 2012 and 2018 at Veterans Affairs Medical Centers. Descriptive statistics summarized antibiotics; propensity score adjusted regression models were fit to compare outcomes.Two hundred and seventy-six patients with 439 XDRAB cultures and Gram-negative targeted antibiotic treatment were included. One hundred and eighteen (43%) patients received monotherapy while 158 (57%) received combination therapy, most commonly including a carbapenem (n = 106, 67%) and polymyxin (n = 66, 42%). One hundred and eighty-four (67%) patients received inadequate treatment. In adjusted models, combination therapy did not decrease the odds of in-hospital (aOR 1.24, 95%CI 0.60-2.59) or 30-day (aOR 1.43, 95%CI 0.86-2.38) mortality, or median postculture length of stay (aIRR 1.11, 95%CI 0.86-1.43). Likewise, receipt of inadequate treatment was not associated with poorer outcomes.In this national cohort of patients with XDRAB, neither combination therapy nor receipt of adequate treatment improved outcomes. Further research is needed on optimal management of this difficult-to-treat pathogen with few effective antibiotic options.

Background Peripherally inserted central catheters (PICCs) and midlines are commonly used devices for reliable vascular access. Infection and thrombosis are the main adverse effects of these catheters. We aimed to evaluate the relative risk of complications from midlines and PICCs. Methods We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies. The primary outcomes were catheter-related bloodstream infection (CRBSI) and thrombosis. Secondary outcomes evaluated included mortality, failure to complete therapy, catheter occlusion, phlebitis, and catheter fracture. The certainty of evidence was assessed using the GRADE approach. Results Of 8368 citations identified, 20 studies met the eligibility criteria, including 1 RCT and 19 observational studies. Midline use was associated with fewer patients with CRBSI compared with PICCs (odds ratio [OR], 0.24; 95% CI, 0.15–0.38). This association was not observed when we evaluated risk per catheter. No significant association was found between catheters when evaluating risk of localized thrombosis and pulmonary embolism. A subgroup analysis based on location of thrombosis showed higher rates of superficial venous thrombosis in patients using midlines (OR, 2.30; 95% CI, 1.48–3.57). We did not identify any significant difference between midlines and PICCs for the secondary outcomes. Conclusions Our findings suggest that patients who use midlines might experience fewer CRBSIs than those who use PICCs. However, the use of midline catheters was associated with greater risk of superficial vein thrombosis. These findings can help guide future cost-benefit analyses and direct comparative RCTs to further characterize the efficacy and risks of PICCs vs midline catheters.

Background Current methods for displaying summary antibiograms are static, have limited utility and are not user friendly. We present an interactive web application for visualization of antibiogram data. Methods Antibiotic susceptibility data for first, non-duplicate patient infection isolates with source/site data were collected from 2009–2018 at an integrated health system for the visualizations. Iterative user-centered design sessions were held with healthcare providers to guide prototype development, including assessment of source groupings and rational for aggregating data. Three providers participated in initial and follow-up sessions (6 total) with study personnel. Data were aggregated by agreed-upon infection-source and pathogen; antibiotic results with < 30 isolates were excluded. Results The multi-year dataset included 119,333 non-duplicative isolates from 194 unique infection sites; nearly half were E. coli (n=50,404). Final infection source groupings with interactive data visualization fields are shown in Figure 1. First an infection source is selected; the visualization then shows pathogen prevalence in descending order. Providers can view susceptibility results for all antibiotics or deselect all and view only those under consideration, such as the four displayed in Figure 1. Resulting bar charts allow providers to view which pathogens tested have greater than 80% or 90% susceptibility to each antibiotic. Susceptibilities for multiple pathogens can also be visualized with the dodged feature (Figure 2). The large dataset collected supports source-specific susceptibility results (e.g. eye infections). The visualization allows providers to see how susceptibility by pathogen may cross clinically meaningful thresholds of 80% and 90% for different infection sources, such as urinary tract compared to bloodstream infections. Feedback from providers on the prototype was overwhelmingly positive. Figure 1.Visualization of urine isolates, E. coli and user selected antibiotics Final source groupings: Urine, Skin/Soft Tissue, Blood, Respiratory Secretions, Fluid, Ear, Bone, Vaginal/Perianal, Eye, and Abscess. Figure 2.Selected antibiotic susceptibilities for multiple pathogens can be visualized simultaneously with the dodged feature. Conclusion Our interactive antibiogram data clinical decision support tool extends the utility of the traditional lab-generated antibiogram. Importantly, future iterations will include visualizing changes by year, by clinical setting (inpatient vs. outpatient) and an assessment of uptake of this tool in the clinical setting. Disclosures All Authors: No reported disclosures.

Background In 2017, our adult tertiary care academic hospital in the Midwest implemented an inpatient fluoroquinolone (FQ) prior authorization (PA) policy using the electronic health record (EHR) as a stewardship tool. We examined the changes in antibiotic use, the antibiogram, and antibiotic use at an affiliated hospital without PA but staffed by physicians from the PA site. Methods This quasi-experimental study used a pre-post implementation design to evaluate a PA policy at our University Hospital requiring approval of all inpatient FQ use from the antimicrobial stewardship physician or infectious disease consult teams. Time periods consisted of 2.5 year pre-implementation, 9-month wash-in (pilot on 2 wards), and 5-year post-implementation periods. Monthly antibiotic use in days of therapy per 1000 patient days (DOT/KPD) and antibiogram data, limited to first inpatient culture per patient per week from any anatomic site, were collected. Monthly FQ use from an affiliated hospital without the restriction policy staffed by physicians from the University Hospital was also collected. Changes in antibiotic use were examined using t-test, or Mann-Whitney Rank Sum, and antibiotic susceptibility rates were compared using z-test. Results Following implementation of PA, FQ use decreased by 76% (-53.2 DOT/KPD, p< 0.001) (Fig. 1). FQ use also declined from 26.4 DOT/KPD to 7.7 DOT/KPD (p< 0.001) at the affiliated hospital without PA but staffed by physicians from University Hospital. Changes in gram-negative agents use are shown in Table 1, with greatest increase noted for ceftriaxone (∼50%). The ciprofloxacin inpatient antibiogram improved significantly (Table 2); whereas, a slight decline in susceptibility was noted for ceftriaxone and cefepime. Figure 1.Fluoroquinolone use across study periods. Wash-in period included a pilot fluoroquinolone prior authorization in 2 wards. Abbreviations: Days of Therapy (DOT); patient days (PD) Table 1.Mean antibiotic days of therapy during each study period. Successive shortages for cefepime and piperacillin-tazobactam during the wash-in period, as indicated by NA. Table 2.Proportion of susceptible isolates pre- and post-implementation of Fluoroquinolone prior-authorization.Pip-tazo, piperacillin-tazobactam; %S, the percent susceptible for Pre- or Post-implementation periods; * indicates significant improvement and ¥ significant decline (p Conclusion FQ PA leads to significant and sustained decline in FQ use, indicating that suitable alternative choices exist for most hospitalized patients. Decreased FQ use was associated with increased use of cephalosporins, mainly ceftriaxone. As might be expected, changes in use were associated with subsequent changes in the antibiogram. This intervention was associated with a significant decline in FQ use at a site without the restriction policy and the EHR modifications, suggesting successful diffusion of educational and behavioral changes. Disclosures Lindsay Taylor, MD, Merck: Grant/Research Support Jessica S. Tischendorf, MD, MS, Merck: Grant/Research Support.

Background Validated tools to evaluate organizational readiness exist within the implementation science literature, but readiness assessments for healthcare organization participation in cluster randomized control trials (CRCTs) have not been developed. CRCTs have been important for increasing the evidence base for infection control. This study describes complex contextual factors that can impact participation in a multi-site infection control CRCTs within the VA healthcare system. Methods To assess study participation eligibility and feasibility, a survey of ten inpatient acute care patient units within five VA healthcare facilities was conducted to evaluate standard eligibility criteria such as facility and patient unit demographics, infection rates, and letters of support from leadership. With study delays we began conducting readiness evaluations through email communications and conference calls. We identified several metrics of readiness including competing priorities, identification of champions/ stakeholder engagement, and research infrastructure. Results Our Initial survey metrics received from facilities interested in study participation were efficient in detecting study eligibility but lacked efficiency to detect study feasibility. Later metrics identified barriers to feasible study implementation (i.e., readiness), primarily competing priorities, specifically due to the pandemic. Other barriers included the lack of research infrastructure and lack of champion identification/stakeholder engagement. These contextual factors were generally elicited through ongoing communication rather than from the initial survey assessment. Conclusion Organizational readiness can delay or impede important infection control CRCTs. This study exemplifies the complexity of healthcare organizations participation in clinical studies that may not be addressed in existing readiness tools or assessments. The emergence of the covid pandemic amplified the importance of identifying a wide range of contextual factors that need to be captured in ongoing assessments for readiness. An essential first step in developing organizational readiness tools and assessments is to identify and define readiness constructs in complex changing healthcare settings. Disclosures All Authors: No reported disclosures.

The importance of antimicrobial stewardship (AMS) activities specifically focused on solid organ transplant (SOT) recipients is increasingly recognized. In 2014, the Veterans Health Administration (VHA) created national guidance and committed resources to establish AMS programs at Veterans Affairs (VA) medical centers across the country. However, the AMS implementation is at the discretion of individual VA centers.We undertook an environmental scan of AMS activities in a tertiary care VA medical center.We describe AMS activities focused on SOT recipients. Strategies based on local epidemiology that leverage the electronic medical record together with engagement by transplant infectious diseases personnel are likely to be beneficial.AMS in SOT recipients is challenging yet impactful. Strategies described here may be useful for AMS activities focused on the SOT population.

Background An outbreak of Legionella pneumonia occurred at a university hospital using copper-silver ionization for potable water disinfection. We present the epidemiological and laboratory investigation of the outbreak, and associated case-control study. Methods Cases were defined by syndrome compatible with Legionella pneumonia with laboratory-confirmed Legionella infection. The water circuit and disinfection system were assessed, and water samples collected for Legionella culture. Whole genome multi-locus sequence typing (wgMLST) was used to compare the genetic similarity of patient and environmental isolates. A case-control study was conducted to identify risk factors for Legionella pneumonia. Results We identified 13 cases of hospital-acquired Legionella. wgMLST revealed >99.9% shared allele content among strains isolated from clinical and water samples. Smoking (P= .008), steroid use (P= .007), and documented shower during hospitalization (P= .03) were risk factors for Legionella pneumonia on multivariable analysis. Environmental assessment identified modifications to the hospital water system had occurred in the month preceding the outbreak. Multiple mitigation efforts and application of point of use water filters stopped the outbreak. Conclusions Potable water system Legionella colonization occurs despite existing copper-silver ionization systems, particularly after structural disruptions. Multidisciplinary collaboration and direct monitoring for Legionella are important for outbreak prevention. Showering is a modifiable risk factor for nosocomial Legionella pneumonia. Shower restriction and point-of-use filters merit consideration during an outbreak.

Antibiotic use is often the target of interventions in health care organizations that aim to decrease healthcare-associated infections (HAI) such as Clostridioides difficile (CDI); this is particularly important for fluoroquinolones (FQ), which are frequently used in critical care settings. In this study, using a multiple case study research approach, we conduct an in-depth analysis of an intervention aimed at limiting ICU prescriber access to FQ in two ICUs of two hospitals. The data collection and analysis were guided by a human factors engineering approach based on the SEIPS (Systems Engineering Initiative for Patient Safety) model and evidence-based implementation principles. Our results show some differences in the implementation of the FQ intervention between the two ICUs, such as level and method of FQ restriction, and training and communication with physicians and pharmacists. In both ICUs, several organizational learning mechanisms helped to quickly identify problems with the intervention and ensure that changes were made in a just-in-time manner (e.g. just-in-time training, removal of FQ in order set for pneumonia). Despite their organizational differences, both sites developed strategies to successfully implement the FQ intervention.

Background Daily use of chlorhexidine gluconate (CHG) has been shown to reduce risk of healthcare-associated infections. We aimed to assess moving CHG bathing into routine practice using a human factors approach. We evaluated implementation in non-intensive care unit (ICU) settings in the Veterans Health Administration. Methods Our multiple case study approach included non-ICU units from 4 Veterans Health Administration settings. Guided by the Systems Engineering Initiative for Patient Safety, we conducted focus groups and interviews to capture barriers and facilitators to daily CHG bathing. We measured compliance using observations and skin CHG concentrations. Results Barriers to daily CHG include time, concern of increasing antibiotic resistance, workflow and product concerns. Facilitators include engagement of champions and unit shared responsibility. We found shortfalls in patient education, hand hygiene and CHG use on tubes and drains. CHG skin concentration levels were highest among patients from spinal cord injury units. These units applied antiseptic using 2% CHG impregnated wipes vs 4% CHG solution/soap. Discussion Non-ICUs implementing CHG bathing must consider human factors and work system barriers to ensure uptake and sustained practice change. Conclusions Well-planned rollouts and a unit culture promoting shared responsibility are key to compliance with daily CHG bathing. Successful implementation requires attention to staff education and measurement of compliance.

Antibiotic-associated diarrhea and Clostridioides difficile infection (CDI) occur frequently among adults. The pathophysiology of CDI is related to disruption of normal gut flora and risk factors include hospitalization, use of antibiotic therapy, and older age. Clinical manifestations can range from mild disease to toxic megacolon. Diagnosis is challenging and is based on a combination of clinical symptoms and diagnostic tests. Therapy includes cessation of antibiotics, or use of other agents depending on the severity of illness. Many novel agents for the treatment and prevention of CDI show promise and are under investigation.

Of 10 surgeons interviewed in a descriptive qualitative study, 6 believed that surgical site infections are inevitable. Bundle adherence was felt to be more likely with strong evidence-based measures developed by surgical leaders. The intrinsic desire to excel was viewed as the main adherence motivator, rather than “pay-for-performance” models.

The aim of this research was to describe the incidence and treatments of mastitis and other common bovine diseases using one year of retrospective observational data (n = 50,329 cow-lactations) obtained from herd management software of 37 large dairy farms in Wisconsin. Incidence rate (IR) was defined as the number of first cases of each disease divided by the number of lactations per farm. Clinical mastitis (CM) remains the most diagnosed disease of dairy cows. Across all herds, the mean IR (cases per 100 cow-lactations) was 24.4 for clinical mastitis, 14.5 for foot disorders (FD), 11.2 for metritis (ME), 8.6 for ketosis (KE), 7.4 for retained fetal membranes (RFM), 4.5 for diarrhea (DI), 3.1 for displaced abomasum (DA), 2.9 for pneumonia (PN) and 1.9 for milk fever (MF). More than 30% of cows that had first cases of CM, DA, RFM, DI, and FD did not receive antibiotics. Of those treated, more than 50% of cows diagnosed with PN, ME and CM received ceftiofur as a treatment. The IR of mastitis and most other diseases was greater in older cows (parity ≥ 3) during the first 100 days of lactation and these cows were more likely to receive antibiotic treatments (as compared to younger cows diagnosed in later lactation). Cows of first and second parities in early lactation were more likely to remain in the herd after diagnosis of disease, as compared to older cows and cows in later stages of lactation. Most older cows diagnosed with CM in later lactation were culled before completion of the lactation. These results provide baseline data for disease incidence in dairy cows on modern U.S. dairy farms and reinforce the role of mastitis as an important cause of dairy cow morbidity.

Introduction The composition of the nasal microbiota in surgical patients in the context of general anesthesia and nasal povidone-iodine decolonization is unknown. The purpose of this quality improvement study was to determine: (i) if general anesthesia is associated with changes in the nasal microbiota of surgery patients and (ii) if preoperative intranasal povidone-iodine decolonization is associated with changes in the nasal microbiota of surgery patients. Materials and methods One hundred and fifty-one ambulatory patients presenting for surgery were enrolled in a quality improvement study by convenience sampling. Pre- and post-surgery nasal samples were collected from patients in the no intranasal decolonization group (control group, n = 54). Pre-decolonization nasal samples were collected from the preoperative intranasal povidone-iodine decolonization group (povidone-iodine group, n = 97). Intranasal povidone-iodine was administered immediately prior to surgery and continued for 20 minutes before patients proceeded for surgery. Post-nasal samples were then collected. General anesthesia was administered to both groups. DNA from the samples was extracted for 16S rRNA sequencing on an Illumina MiSeq. Results In the control group, there was no evidence of change in bacterial diversity between pre- and post-surgery samples. In the povidone-iodine group, nasal bacterial diversity was greater in post-surgery, relative to pre-surgery (Shannon’s Diversity Index (P = 0.038), Chao’s richness estimate (P = 0.02) and Inverse Simpson index (P = 0.027). Among all the genera, only the relative abundance of the genus Staphylococcus trended towards a decrease in patients after application (FDR adjusted P = 0.06). Abundant genera common to both povidone-iodine and control groups included Staphylococcus, Bradyrhizobium, Corynebacterium, Dolosigranulum, Lactobacillus, and Moraxella. Conclusions We found general anesthesia was not associated with changes in the nasal microbiota. Povidone-iodine treatment was associated with nasal microbial diversity and decreased abundance of Staphylococcus. Future studies should examine the nasal microbiota structure and function longitudinally in surgical patients receiving intranasal povidone-iodine.

Diet is widely recognized as a key contributor to human gut microbiome composition and function. However, overall nutrition can be difficult to compare across a population with varying diets. Moreover, the role of food security in the relationship with overall nutrition and the gut microbiome is unclear. This study aims to investigate the association between personalized nutrition scores, variation in the adult gut microbiome, and modification by food insecurity. The data originate from the Survey of the Health of Wisconsin and the Wisconsin Microbiome Study. Individual nutrition scores were assessed using My Nutrition Index (MNI), calculated using data from food frequency questionnaires, and additional health history and demographic surveys. Food security and covariate data were measured through self-reported questionnaires. The gut microbiome was assessed using 16S amplicon sequencing of DNA extracted from stool samples. Associations, adjusted for confounding and interaction by food security, were estimated using Weighted Quantile Sum (WQS) regression models with Random Subset and Repeated Holdout extensions (WQSRSRH), with bacterial taxa used as components in the weighted index. Of 643 participants, the average MNI was 66.5 (SD = 31.9), and 22.8% of participants were food insecure. Increased MNI was significantly associated with altered gut microbial composition (β = 2.56, 95% CI = 0.52–4.61), with Ruminococcus, Oscillospira, and Blautia among the most heavily weighted of the 21 genera associated with the MNI score. In the stratified interaction WQSRSRH models, the bacterial taxa most heavily weighted in the association with MNI differed by food security, but the level of association between MNI and the gut microbiome was not significantly different. More bacterial genera are important in the association with higher nutrition scores for people with food insecurity versus food security, including Streptococcus, Parabacteroides Faecalibacterium, and Desulfovibrio. Individual nutrition scores are associated with differences in adult gut microbiome composition. The bacterial taxa most associated with nutrition vary by level of food security. While further investigation is needed, results showed a higher nutrition score was associated with a wider range of bacterial taxa for food insecure vs. secure, suggesting nutritional quality in food insecure individuals is important in maintaining health and reducing disparities.

Background The effectiveness of enhanced terminal room cleaning with ultraviolet C (UV-C) disinfection in reducing gram-negative rod (GNR) infections has not been well evaluated. We assessed the association of implementation of UV-C disinfection systems with incidence rates of hospital-onset (HO) GNR bloodstream infection (BSI). Methods We obtained information regarding UV-C use and the timing of implementation through a survey of all Veterans Health Administration (VHA) hospitals providing inpatient acute care. Episodes of HO-GNR BSI were identified between January 2010 and December 2018. Bed days of care (BDOC) was used as the denominator. Over-dispersed Poisson regression models were fitted with hospital-specific random intercept, UV-C disinfection use for each month, baseline trend, and seasonality as explanatory variables. Hospitals without UV-C use were also included to the analysis as a nonequivalent concurrent control group. Results Among 128 VHA hospitals, 120 provided complete survey responses with 40 reporting implementations of UV-C systems. We identified 13 383 episodes of HO-GNR BSI and 24 141 378 BDOC. UV-C use was associated with a lower incidence rate of HO-GNR BSI (incidence rate ratio: 0.813; 95% confidence interval: .656–.969; P = .009). There was wide variability in the effect size of UV-C disinfection use among hospitals. Conclusions In this large quasi-experimental analysis within the VHA System, enhanced terminal room cleaning with UV-C disinfection was associated with an approximately 19% lower incidence of HO-GNR BSI, with wide variability in effectiveness among hospitals. Further studies are needed to identify the optimal implementation strategy to maximize the effectiveness of UV-C disinfection technology.

Objective:Influenza can be introduced and propagated in healthcare settings by healthcare workers (HCWs) working while ill with influenza. However, reasons driving this behavior are unclear. In this study, we examined barriers to and facilitators of absenteeism during the influenza season.Design:Cross-sectional mixed methods study.Setting:Ambulatory and inpatient settings in a large, tertiary-care healthcare system.Methods:An anonymous electronic survey was sent to HCWs between June 11 and July 13, 2018, asking participants to self-report influenza-like illness (ie, ILI symptoms of fever, chills, cough, or sore throat) during the 2017–2018 influenza season. We conducted a logistical regression analysis to identify factors associated with absenteeism.Results:Of 14,250 HCWs, 17% responded to the survey. Although 1,180 respondents (51%) reported symptoms of ILI, 575 (43%) did not stay home while ill. The most commonly perceived barriers to ILI absenteeism included being understaffed (odds ratio [OR], 1.78; P = .04), unable to find a replacement for work (OR, 2.26; P = .03), desiring not to use time off (OR, 2.25; P = .003), and paid by the hour or unable to afford being absent (OR, 2.05; P = .02). Common perceived facilitators of absenteeism included support from coworkers and management, clearer policy, better sick days availability, and lower perceived threat of disciplinary action.Conclusions:Reporting to work with ILI symptoms is common among HCWs. Most barriers and facilitators are related to systems. Addressing system factors, such as policies regarding sick days and sick leave and ensuring adequate backup staffing, is likely to facilitate absenteeism among ill HCWs.

The impact of variability in infection surveillance methodologies on publicly reported rates of surgical site infection (SSI) is not well defined.We performed a cross-sectional study to assess infection preventionists' surveillance practices across acute care US hospitals. We collected self-reported annual facility standardized infection ratios for colon surgery and abdominal hysterectomy as provided by the National Healthcare Safety Network. Trend analysis using Kendall's rank correlation evaluated the association between surveillance rigor and SSI rates.Among 492 participating hospitals, 63%, 15%, 13%, and 8% were community, university-affiliated, critical access, and ambulatory surgical centers, respectively. Most critical access hospitals (82%) and ambulatory surgical centers (98%) reported less than one full time infection preventionists (P ≤ .001). University-affiliated medical centers spent significantly more time and used more data sources for monthly SSI review compared with other hospitals. Critical access hospitals and ambulatory surgical centers were more likely to rely on manual surveillance only (P.001). The number of different data sources used for SSI surveillance was positively associated with higher SSI rates: (KRigorous SSI surveillance using more data sources for case-finding is more likely to be associated with higher facility SSI rates for colon surgery and abdominal hysterectomy.

A review of nasal sprays and gargles with antiviral properties suggests that a number of commonly used antiseptics including povidone-iodine, Listerine®, iota-carrageenan and chlorhexidine should be studied in clinical trials to mitigate both the progression and transmission of SARS-CoV-2. Several of these antiseptics have demonstrated the ability to cut the viral load of SARS-CoV-2 by 3–4 log10 in 15–30 s in vitro. In addition, hypertonic saline targets viral replication by increasing hypochlorous acid inside the cell. A number of clinical trials are in process to study these interventions both for prevention of transmission, prophylaxis after exposure, and to diminish progression by reduction of viral load in the early stages of infection., Tweetable abstract Commonly used antiseptics including povidone-iodine, Listerine®, iota-carrageenan and chlorhexidine should be studied in clinical trials to mitigate the progression and transmission of SARS-CoV-2.

BACKGROUND: Across the United States, various social distancing measures were implemented to control the spread of coronavirus disease 2019 (COVID-19). However, the effectiveness of such measures for specific regions with varying population demographic characteristics and different levels of adherence to social distancing is uncertain. OBJECTIVE: To determine the effect of social distancing measures in unique regions. DESIGN: An agent-based simulation model. SETTING: Agent-based model applied to Dane County, Wisconsin; the Milwaukee metropolitan (metro) area; and New York City (NYC). PATIENTS: Synthetic population at different ages. INTERVENTION: Different times for implementing and easing social distancing measures at different levels of adherence. MEASUREMENTS: The model represented the social network and interactions among persons in a region, considering population demographic characteristics, limited testing availability, "imported" infections, asymptomatic disease transmission, and age-specific adherence to social distancing measures. The primary outcome was the total number of confirmed COVID-19 cases. RESULTS: The timing of and adherence to social distancing had a major effect on COVID-19 occurrence. In NYC, implementing social distancing measures 1 week earlier would have reduced the total number of confirmed cases from 203 261 to 41 366 as of 31 May 2020, whereas a 1-week delay could have increased the number of confirmed cases to 1 407 600. A delay in implementation had a differential effect on the number of cases in the Milwaukee metro area versus Dane County, indicating that the effect of social distancing measures varies even within the same state. LIMITATION: The effect of weather conditions on transmission dynamics was not considered. CONCLUSION: The timing of implementing and easing social distancing measures has major effects on the number of COVID-19 cases. PRIMARY FUNDING SOURCE: National Institute of Allergy and Infectious Diseases.

A survey of Veterans’ Affairs Medical Centers on control of carbapenem-resistant Enterobacteriaceae (CRE) and carbapenem-producing CRE (CP-CRE) demonstrated that most facilities use VA guidelines but few screen for CRE/CP-CRE colonization regularly or regularly communicate CRE/CP-CRE status at patient transfer. Most respondents were knowledgeable about CRE guidelines but cited lack of adequate resources.

The microbiome is composed of many organisms and is impacted by an intricate exchange between genetics and environmental factors. The perinatal microbiome influences both the developing fetus and the pregnant person. The purpose of this article is to describe the tests that are currently available for laboratory analysis of the perinatal microbiome in relationship to probiotic interventions. This article focuses on the bacterial component of the microbiome. Although adverse outcomes associated with the perinatal microbiome have been studied, a comprehensive understanding of the physiologic perinatal microbiome is still emerging. Early efforts to influence the perinatal microbiome through probiotics are currently under investigation. Unique terminology is defined, and the microbial composition of perinatal microbiota is summarized. The outcomes of studies of antenatal probiotics are summarized. Microbiome testing and analysis are defined and compared. Implications for perinatal care and probiotics research are presented.

A number of important principles in effective risk communication established in the late 20th century can provide important scientific insight into patient response to the risks posed by COVID-19 [1-3]. Early risk communication scholars studied public perceptions of risk in response to environmental disasters, or infectious disease outbreaks. They found acceptability of risk, and any limitations and acceptability of response by experts was shaped by two key components: hazard and outrage. The number of people who are exposed, infected and fall ill can be considered the hazard. How the public and patients perceive the risk and respond to messages regarding risk mitigation relates to outrage. Social and cultural factors, immediacy, uncertainty, familiarity, personal control, scientific uncertainty and trust in institutions and media all shape acceptability of response. These outrage factors influence the ever-changing public understanding of COVID-19 risk, as well as the public’s acceptance of personal and societal mitigation strategies. Risk perceptions and acceptability of mitigation strategies are also largely shaped in the context of culture and society. In concert, hazard and outrage along with cultural and economic context shape adherence to, and overall acceptance of, personal mitigation strategies including wearing facemasks, and social distancing among the general public. The spread of misinformation on social media in the context of crisis communication provides both challenges and opportunities for experts and officials to effectively communicate and influence these outrage factors. Social media offers an opportunity for experts to quickly convey true information about hazards, but offers others the opportunity to counter this with the spread of misinformation and exacerbate outrage. We propose strategies for infectious diseases clinicians to apply risk communication principles and frameworks to improve patient care and public message development in response to COVID-19.

The gut microbiome is an important feature of host immunity with associations to hematologic malignancies and cellular therapy. We evaluated the gut microbiome and dietary intake in patients with multiple myeloma undergoing autologous stem cell transplantation. Thirty patients were enrolled and samples were collected at 4 timepoints: pre-transplant, engraftment, day +100 (D+100), and 9-12 months post-transplant. Microbiome analysis demonstrated a loss of alpha diversity at the engraftment timepoint driven by decreases in Blautia, Ruminococcus, and Faecalibacterium genera and related to intravenous antibiotic exposure. Higher fiber intake was associated with increased relative abundance of Blautia at the pre-transplant timepoint. Lower alpha diversity at engraftment was associated with a partial response to therapy compared to complete response (CR) or very good partial response (VGPR) (CR/VGPR vs. PR, p

Objectives: Contaminated surfaces in healthcare settings contribute to the transmission of nosocomial pathogens. Adequate environmental cleaning is important for preventing the transmission of important pathogens and reducing healthcare-associated infections. However, effective cleaning practices vary considerably. We examined environmental management services (EMS) staff experiences and perceptions surrounding environmental cleaning to describe perceived challenges and ideas to promote an effective environmental services program. Design: Qualitative study. Participants: Frontline EMS staff. Methods: From January to June 2019, we conducted individual semistructured interviews with key stakeholders (ie, EMS staff) at 3 facilities within the Veterans’ Affairs Healthcare System. We used the Systems Engineering Initiative for Patient Safety (SEIPS) framework (ie, people, environment, organization, tasks, tools) to guide this study. Interviews were audio-recorded, transcribed, and analyzed for thematic content. Results: In total, 13 EMS staff and supervisors were interviewed. A predominant theme that emerged were the challenges EMS staff saw as hindering their ability to be effective at their jobs. EMS staff interviewed felt they understand their job requirements and are dedicated to their work; however, they described challenges related to feeling undervalued and staffing issues. Conclusions: EMS staff play a critical role in infection prevention in healthcare settings. However, some do not believe their role is recognized or valued by the larger healthcare team and leadership. EMS staff provided ideas for improving feelings of value and job satisfaction, including higher pay, opportunities for certifications and advancement, as well as collaboration or integration with the larger healthcare team. Healthcare organizations should focus on utilizing these suggestions to improve the EMS work climate.

Prolonged infections in immunocompromised individuals may be a source for novel SARS-CoV-2 variants, particularly when both the immune system and antiviral therapy fail to clear the infection and enable within-host evolution. Here we describe a 486-day case of SARS-CoV-2 infection in an immunocompromised individual. Following monotherapy with the monoclonal antibody Bamlanivimab, the individual’s virus acquired resistance, likely via the earliest known occurrence of Spike amino acid variant E484T. Recently, E484T has arisen again as a derivative of E484A in the Omicron Variant of Concern, supporting the hypothesis that prolonged infections can give rise to novel variants long before they become prevalent in the human population.

Background Clostridioides difficile infections (CDI) and recurrence (rCDI) are major health care burdens. Recurrence is likely caused by spores in the gastrointestinal tract that germinate after antibiotic therapy. This murine study explores germinant-antibiotic combinations for CDI. Methods Previously described murine models were evaluated using C. difficile VPI 10463. The severe model compared omadacycline versus vancomycin in survival, weight loss, clinical scoring, and C. difficile toxin production. The nonsevere model compared these antibiotics with and without germinants (solution of sodium taurocholate, taurine, sodium docusate, calcium gluconate). Additionally, colon histopathology, bile acid analysis, environmental/spore shedding, and 16S sequencing was evaluated. Results In the severe model, omadacycline-treated mice had 60% survival versus 13.3% with vancomycin (hazard ratio [HR], 0.327; 95% confidence interval [CI],.126–.848; P = .015) along with decreased weight loss, and disease severity. In the nonsevere model, all mice survived with antibiotic-germinant treatment versus 60% antibiotics alone (HR, 0.109; 95% CI, .02–.410; P = .001). Omadacycline resulted in less changes in bile acids and microbiota composition. Germinant-treated mice showed no signs of rCDI, spore shedding, or significant toxin production at 15 days. Conclusions In murine models of CDI, omadacycline improved survival versus vancomycin. Germinant-antibiotic combinations were more effective at preventing rCDI compared to antibiotics alone without inducing toxin production.

As agent-based models (ABMs) are increasingly used for modeling infectious diseases, model validation is becoming more crucial. In this study, we present an alternate approach to validating hospital ABMs that focuses on replicating hospital-specific conditions and proposes a new metric for validating the social-environmental network structure of ABMs. We adapted an established ABM representing Clostridioides difficile infection (CDI) spread in a generic hospital to a 426-bed Midwestern academic hospital. We incorporated hospital-specific layout, agent behaviors, and input parameters estimated from primary hospital data into the model, referred to as H-ABM. We compared the predicted CDI rate against the observed rate from 2013–2018. We used colonization pressure, a measure of nearby infectious agents, to validate the socio-environmental agent networks in the ABM. Finally, we conducted additional experiments to compare the performance of individual infection control interventions in the H-ABM and the generic model. We find that the H-ABM is able to replicate CDI trends during 2013–2018, including a roughly 46% drop during a period of greater infection control investment. High CDI burden in socio-environmental networks was associated with a significantly increased risk of C. difficile colonization or infection (Risk ratio: 1.37; 95% CI: [1.17, 1.59]). Finally, we found that several high-impact infection control interventions have diminished impact in the H-ABM. This study presents an alternate approach to validation of ABMs when large-scale calibration is not appropriate for specific settings and proposes a new metric for validating socio-environmental network structure of ABMs. Our findings also demonstrate the utility of hospital-specific modeling.

Two years after the emergence of SARS-CoV-2, there is still a need for better ways to assess the risk of transmission in congregate spaces. We deployed active air samplers to monitor the presence of SARS-CoV-2 in real-world settings across communities in the Upper Midwestern states of Wisconsin and Minnesota. Over 29 weeks, we collected 527 air samples from 15 congregate settings. We detected 106 samples that were positive for SARS-CoV-2 viral RNA, demonstrating that SARS-CoV-2 can be detected in continuous air samples collected from a variety of real-world settings. We expanded the utility of air surveillance to test for 40 other respiratory pathogens. Surveillance data revealed differences in timing and location of SARS-CoV-2 and influenza A virus detection. In addition, we obtained SARS-CoV-2 genome sequences from air samples to identify variant lineages. Collectively, this shows air sampling is a scalable, high throughput surveillance tool that could be used in conjunction with other methods for detecting respiratory pathogens in congregate settings.

The species composition of the human gut microbiota is related to overall health, and a healthy gut microbiome is crucial in maintaining colonization resistance against pathogens. Disruption of gut microbiome composition and functionality reduces colonization resistance and has been associated with several gastrointestinal and non-gastrointestinal diseases. One prime example is

Midcareer women faculty face unique career challenges that may benefit from mentorship and sponsorship, yet such programs focused on the needs of this career phase are scarce in academic medicine. Many midcareer faculty require intentional and individual career planning to choose a path from the broad array of options in academic medicine. Ambiguous promotion criteria, increased workloads because of service or citizenship tasks, and a lack of sponsorship are among the barriers that inhibit midcareer faculty's growth into the high-visibility roles needed for career advancement. In addition, issues faced by women midcareer faculty members may be further exacerbated by barriers such as biases, a disproportionate share of family responsibilities, and inequities in recognition and sponsorship. These barriers contribute to slower career growth and higher attrition among women midcareer faculty and ultimately an underrepresentation of women among senior leadership in academic medicine. Here, we describe how a mentoring program involving individuals (eg, mentors, mentees, and sponsors) and departments/institutions (eg, deans and career development offices) can be used to support midcareer faculty. We also provide recommendations for building a mentoring program with complementary support from sponsors targeted toward the specific needs of women midcareer faculty. A robust midcareer mentoring program can support the career growth and engagement of individual faculty members and as a result improve the diversity of academic medicine's highest ranks.

Objective: To compare clinical outcomes associated with appropriate and inappropriate management of asymptomatic bacteriuria (ASB) and urinary tract infection (UTI) among inpatients with neurogenic bladder (NB). Design: Multicenter, retrospective cohort. Setting: The study was conducted across 4 Veterans’ Affairs hospitals. Participants: The study included veterans with NB due to spinal cord injury or disorder (SCI/D), multiple sclerosis (MS), or Parkinson’s disease (PD) hospitalized between January 1, 2017, and December 31, 2018, with diagnosis of ASB or UTI. Interventions: In a medical record review, we classified ASB and UTI diagnoses and treatments as appropriate or inappropriate based on national guidelines. Main outcome measures: Frequencies of Clostridioides difficile infection, acute kidney injury, 90-day hospital readmission, postculture length-of-stay (LOS), and multidrug-resistant organisms in subsequent urine cultures were compared between those who received appropriate and inappropriate management. Results: We included 170 encounters with ASB (30%) or UTI (70%) diagnoses occurring for 166 patients. Overall, 86.1% patients were male, 47.6% had SCI/D and 77.6% used bladder catheters. All ASB encounters had appropriate diagnoses, and 96.1% had appropriate treatment. In contrast, 37 UTI encounters (31.1%) had inappropriate diagnoses and 61 (51.3%) had inappropriate treatment, including 30 encounters with true ASB. Among patients with SCI/D or MS, appropriate ASB or UTI diagnosis was associated with a longer postculture LOS (median, 14 vs 7.5 days; P = .02). We did not detect any significant associations between appropriate versus inappropriate diagnosis and treatment and other outcomes. Conclusions: Almost one-third of UTI diagnoses and half of treatments in hospitalized patients with NB are inappropriate. Opportunities exist to improve ASB and UTI management in patients with NB to minimize inappropriate antibiotic use.

Probiotics have been suggested as a strategy to reduce antenatal group B Streptococcus colonization. Although probiotics are known to improve gastrointestinal symptoms, this has not been studied during pregnancy.This study aimed to evaluate the efficacy of a probiotic to reduce: (1) standard-of-care antenatal group B Streptococcus colonization and colony counts and (2) gastrointestinal symptoms of pregnancy.In a double-blind fashion, 109 healthy adult pregnant people were randomized to Florajen3 probiotic or placebo capsules once daily from 28 weeks' gestation until labor onset. Baseline vaginal and rectal study swabs for group B Streptococcus colony-forming units and microbiome analysis were collected at 28 and 36 weeks' gestation. Standard-of-care vaginal to rectal group B Streptococcus swabs were collected from all participants at 36 weeks' gestation and determined the need for intrapartum antibiotic prophylaxis. Data collection included solicitation of adverse events, demographic information, Antepartum Gastrointestinal Symptom Assessment score, yogurt ingestion, sexual activity, and vaginal cleaning practices.A total of 83 participants completed the study to 36 weeks' gestation with no adverse events. Standard-of-care group B Streptococcus colonization was 20.4% in the control group and 15.4% in probiotic group participants (-5%; P=.73). The relative risk for positive standard-of-care vaginal-rectal group B Streptococcus colonization was 1.33 (95% confidence interval, 0.5-3.40) times higher in the control group than in the probiotic group (P=.55). There were no differences in median vaginal (P=.16) or rectal (P=.20) group B streptococcus colony-forming units at baseline or at 36 weeks (vaginal P.999; rectal P=.56). Antepartum Gastrointestinal Symptom Assessment scores were similar at baseline (P=.19), but significantly decreased in probiotic group participants at 36 weeks (P=.02). No covariates significantly altered group B Streptococcus colonization. Significantly more Florajen3 bacteria components were recovered from the vaginal-rectal samples of probiotic group participants (32%; P=.04) compared with controls.The findings of this study provided insufficient evidence for the clinical application of the Florajen3 probiotic intervention to reduce standard-of-care vaginal-rectal group B Streptococcus colonization. The prevalence of group B Streptococcus was lower than expected in the study population, and intervention adherence was poor. Probiotic bacteria colonization of the genitourinary tract occurred more in intervention group participants than in controls and significantly reduced gastrointestinal symptoms of pregnancy.

PurposeThe Population-based Microbiome Research Core (PMRC) is an expandable and longitudinal research core infrastructure to support the study of the human microbiome within the context of environmental, sociodemographic, and health factors. Broadly, the purpose of this infrastructure is to provide new insights into how human-environment interactions affect health through its influence on the composition and function of the microbiome. The PMRC was established as an ancillary study of the Survey of Health of Wisconsin (SHOW) and serves as a platform for ancillary studies, ongoing follow-up of the cohort, and expansion of the microbiome biorepository.ParticipantsThe study recruited adult participants who had previously participated in SHOW’s Wisconsin Microbiome Study (WMS). Over 59% of the eligible WMS participants agreed to provide a repeat stool sample and household samples including dust, high touch surface swabs and outside soil.Findings to datePMRC includes 323 individuals; the majority (96%) were over the age of eighteen, white (84%), urban (75%), and lived in their homes for over one year (92%). Overall, 97% of participants completed the questionnaire and household high-touch surface swab collection, and 93% and 94% completed dust and stool collection, respectively. Soil samples were collected for 86% of all participant homes.Future plansSample protocols developed for the PMRC offer a unique framework for future household-based microbiome research. This infrastructure can support the generation of new knowledge on the role of the home environment in relation to the human microbiome and identify new opportunities for intervention research.

The consequences of past COVID-19 infection for personal health and long-term population immunity are only starting to be revealed. Unfortunately, detecting past infection is currently a challenge, limiting clinical and research endeavors. Widely available anti-SARS-CoV-2 antibody tests cannot differentiate between past infection and vaccination given vaccine-induced anti-spike antibodies and the rapid loss of infection-induced anti-nucleocapsid antibodies. Anti-membrane antibodies develop after COVID-19, but their long-term persistence is unknown. Here, we demonstrate that anti-membrane IgG is a sensitive and specific marker of past COVID-19 infection and persists at least one year. We also confirm that anti-receptor binding domain (RBD) Ig is a long-lasting, sensitive, and specific marker of past infection and vaccination, while anti-nucleocapsid IgG lacks specificity and quickly declines after COVID-19. Thus, a combination of anti-membrane and anti-RBD antibodies can accurately differentiate between distant COVID-19 infection, vaccination, and naïve states to advance public health, individual healthcare, and research goals.

The aerodigestive tract (ADT) is the primary portal through which pathogens and other invading microbes enter the body. As the direct interface with the environment, we hypothesize that the ADT microbiota possess biosynthetic gene clusters (BGCs) for antibiotics and other specialized metabolites to compete with both endogenous and exogenous microbes. From 1,214 bacterial genomes, representing 136 genera and 387 species that colonize the ADT, we identified 3,895 BGCs. To determine the distribution of BGCs and bacteria in different ADT sites, we aligned 1,424 metagenomes, from nine different ADT sites, onto the predicted BGCs. We show that alpha diversity varies across the ADT and that each site is associated with distinct bacterial communities and BGCs. We identify specific BGC families enriched in the buccal mucosa, external naris, gingiva, and tongue dorsum despite these sites harboring closely related bacteria. We reveal BGC enrichment patterns indicative of the ecology at each site. For instance, aryl polyene and resorcinol BGCs are enriched in the gingiva and tongue, which are colonized by many anaerobes. In addition, we find that streptococci colonizing the tongue and cheek possess different ribosomally synthesized and posttranslationally modified peptide BGCs. Finally, we highlight bacterial genera with BGCs but are underexplored for specialized metabolism and demonstrate the bioactivity of Actinomyces against other bacteria, including human pathogens. Together, our results demonstrate that specialized metabolism in the ADT is extensive and that by exploring these microbiomes further, we will better understand the ecology and biogeography of this system and identify new bioactive natural products. IMPORTANCE Bacteria produce specialized metabolites to compete with other microbes. Though the biological activities of many specialized metabolites have been determined, our understanding of their ecology is limited, particularly within the human microbiome. As the aerodigestive tract (ADT) faces the external environment, bacteria colonizing this tract must compete both among themselves and with invading microbes, including human pathogens. We analyzed the genomes of ADT bacteria to identify biosynthetic gene clusters (BGCs) for specialized metabolites. We found that the majority of ADT BGCs are uncharacterized and the metabolites they encode are unknown. We mapped the distribution of BGCs across the ADT and determined that each site is associated with its own distinct bacterial community and BGCs. By further characterizing these BGCs, we will inform our understanding of ecology and biogeography across the ADT, and we may uncover new specialized metabolites, including antibiotics.

Understanding the principles of colonization resistance of the gut microbiome to the pathogen Clostridioides difficile will enable the design of defined bacterial therapeutics. We investigate the ecological principles of community resistance to C. difficile using a synthetic human gut microbiome. Using a dynamic computational model, we demonstrate that C. difficile receives the largest number and magnitude of incoming negative interactions. Our results show that C. difficile is in a unique class of species that display a strong negative dependence between growth and species richness. We identify molecular mechanisms of inhibition including acidification of the environment and competition over resources. We demonstrate that Clostridium hiranonis strongly inhibits C. difficile partially via resource competition. Increasing the initial density of C. difficile can increase its abundance in the assembled community, but community context determines the maximum achievable C. difficile abundance. Our work suggests that the C. difficile inhibitory potential of defined bacterial therapeutics can be optimized by designing communities featuring a combination of mechanisms including species richness, environment acidification, and resource competition., A combination of bottom‐up community assembly and computational modeling reveals determinants of Clostridioides difficile growth in synthetic human gut communities.