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Most recent infection outbreaks caused by unsafe injection practices in the United States have occurred in ambulatory settings. We utilized direct observation and a survey to assess injection practices at 31 clinics. Improper vial use was observed at 13 clinics (41.9%). Pharmacy support and healthcare worker education may improve injection practices.Infect Control Hosp Epidemiol 2017;38:614–616

A prospective quasi-experimental before-and-after study of an electronic medical record–anchored intervention of embedded education on appropriate urine culture indications and indication selection reduced the number of urine cultures ordered for catheterized patients at an academic medical center. This intervention could be a component of CAUTI-reduction bundles.Infect Control Hosp Epidemiol 2017;38:486–488

We conducted a retrospective cohort study to evaluate the utility of self-reported tobacco use for developing a clinical prediction rule for poor outcomes of Clostridium difficile infection. We found that patients with any history of smoking were significantly less likely than never smokers to be cured of their infection within two weeks. Disease recurrence, readmission within thirty days, death before treatment completion, and the severity of Clostridium difficile infection were not associated with smoking status.

Background There is significant inappropriate and overuse of antibiotics in the United States. We describe patterns of self-reported actual use of antibiotics and indications in Wisconsin adults. Methods The Survey of the Health of Wisconsin (SHOW) is an annual health study of a wide range of health determinants and outcomes among a population-based sample of residents with targeted recruitment of underrepresented minorities. In 2016, SHOW initiated WARRIOR (Winning the War on Antibiotic Resistance), an ancillary study that assessed actual antibiotic use and indications among adults. Antibiotics were grouped by pharmacologic class, and indications were grouped into clinical categories. Descriptive statistics and logistic regression were used to examine factors associated with antibiotic use. Results Overall, 756 adults [435 female and 321 male; mean (SD) age=54.2 (16.5)] were recruited, and 256 (33.5%) reported antibiotic use in the past year. Females (OR=1.87, 95% CI: 1.29, 2.70), people with current comorbidities or history of certain health conditions (OR=2.04, 95% CI: 1.23, 3.39), and people with a mental health or developmental condition (OR=1.93, 95% CI: 1.33, 281) were statistically significantly more likely to report antibiotic use. BMI (kg/m2) was slightly higher among antibiotic users (31.2) than nonusers (29.8; P = 0.064). Diabetes, heavy drinking, and smoking history were not correlated with antibiotic use. Top antibiotic classes used were penicillins (31%), macrolides (12%), first-generation cephalosporins (9%), tetracyclines (8%), quinolones (7%), and nitroimidazoles (3%). Top indications reported were upper respiratory infection (URI; 32.3%), dental condition or procedure (21.0%), surgery (12.6%), lower respiratory infection (11%), urinary tract, bladder, or kidney infection (7%), skin or soft-tissue infection (6%), and insect bite or insect-borne infection (6%). Conclusion Antibiotic use varies among Wisconsin adults, and certain groups are more likely to have used antibiotics in the last year. The top two reported indications for antibiotics were categories with known high rates of inappropriate (e.g., URI) and prophylactic (i.e., dental) prescribing. Further studies are needed to determine specific opportunities to reduce antibiotic use in Wisconsin. Disclosures All authors: No reported disclosures.

Background Clostridioides difficile infection (CDI) is the leading cause of healthcare-associated diarrhea and recurs in up to 30% of patients, often requiring readmission. Socioeconomic factors, such as living in a disadvantaged neighborhood may impact readmission but have not been studied. Methods We examined the relationship between neighborhood disadvantage, as measured by the Singh validated area deprivation index (ADI), and 30-day all-cause readmission risk in patients with an index hospital stay with CDI. We analyzed a random 20% sample of national Medicare claims for patients’ initial index hospitalization with a CDI diagnosis in 2014 (n = 19,528) that included each patient’s neighborhood ADI national percentile. The most disadvantaged neighborhoods were categorized as those in the upper 35 percentile, while the least disadvantaged was defined as those in the bottom 65% of national ADI rankings. We evaluated the relationship between ADI percentile and 30-day readmission risk using multivariate logistic regression, controlling for key patient demographics, comorbidities, and hospital/stay characteristics. Results A total of 19,528 patients had an index stay with CDI, 4,899 were readmitted within 30 days. Patients from the most disadvantaged neighborhoods had a higher average rate of readmission compared with those living in the least disadvantaged neighborhoods (28% vs. 24% rate; unadjusted risk ratio = 1.16 [1.10, 1.21]). This relationship held after controlling for confounders. After adjustment, being a resident in the most disadvantaged neighborhoods was associated with a 10% increased risk of readmission (adjusted risk ratio = 1.10 [1.05, 1.16]), which was similar to the effect sizes associated with dual Medicaid-Medicare enrollment status (adjusted risk ratio = 1.09 [1.03, 1.15]) and renal failure (adjusted risk ratio = 1.14 [1.08, 1.21]). Conclusion Living in a disadvantaged neighborhood is associated with an increased 30-day readmission risk similar in magnitude to Medicaid status and renal failure in patients with index hospitalizations of CDI. Future studies should examine whether interventions such as post discharge support and care coordination for patients in disadvantaged neighborhoods may reduce readmissions in this patient population. Disclosures All authors: No reported disclosures.

Patient interviews using the Health Belief Model framework identified thematic patient perceptions of indwelling urinary catheters and catheter-associated urinary tract infections. Generally, patients perceived catheters as convenient and were unaware of catheter alternatives and risks for infection. Better patient education is needed to reduce urinary catheter use and infections.Infect Control Hosp Epidemiol 2016;37:1098–1100

BackgroundSmoking increases hospitalization and healthcare-associated infection. Our primary aim of this pilot, randomized-controlled trial was to examine the feasibility and acceptability of a tobacco cessation intervention compared with usual care in inpatients. S. aureus carriage, healthcare-associated infections and infections post discharge were exploratory outcomes.MethodsCurrent inpatient smokers from a university hospital facility were randomized to usual care or a face to face tobacco cessation counseling session where patients' tobacco use and strategies for quitting were discussed. Patient engagement, satisfaction and withdrawal symptoms were measured at 1week and 12weeks post discharge. Nasal swabs were collected at enrollment and discharge and assessed for S. aureus colonization. P-values were calculated using Fisher's exact and t-tests were used to compare groups.ResultsFor the study's primary outcome, participants reported the intervention as being generally acceptable and reported high overall levels of satisfaction, with a Likert scale score of at least 4/5 for all measures of satisfaction. No subjects utilized free tobacco cessation services after discharge. 83% of the intervention group and 93% of the control group smoked at least one cigarette after discharge. Secondary outcomes with regard to infections showed that, at discharge, 12% of the intervention group (n = 17) and 18% of the control group (n = 22) tested positive for S. aureus. After 3months, 9% of the intervention group developed infection, 41% visited an emergency room, and 24% were readmitted within 3months post-discharge, compared to 27, 32 and 36% of the control group respectively.ConclusionsWith regards to the primary aim of this study, there were overall high levels of satisfaction with the intervention, indicating good feasibility and acceptance among patients. However, more intensive interventions in hospitalized patients and impact on healthcare-associated infections and post-discharge infections should be explored.

Background Over a 2-month period, eight patient cultures in our clinical microbiology laboratory were positive for Clostridium paraputrificum, an uncommon spore-forming microbe. The possibility of a pseudo-outbreak related to contamination in the laboratory’s anaerobic tent was considered. Methods This study occurred at a 505-bed tertiary care university-affiliated teaching hospital. Patient samples were cultured and evaluated following standard protocols, and isolates of C. paraputrificum were identified using matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS). To identify additional cases, MALDI-TOF MS testing reports were manually reviewed and matched to patient records. Concurrently, the laboratory’s anaerobic tent was sampled after cleaning with isopropyl alcohol (and later with bleach or sporicidal disinfectant) following standard procedures and protocols recommended by the tent manufacturer (Coy). Pulsed-field gel electrophoresis (PFGE) was performed on isolates from patients (n = 8) and the anaerobic tent (n = 6). Results Despite cleaning with isopropyl alcohol or bleach, surface samples from the anaerobic tent grew C. paraputrificum. PFGE analysis revealed all patient and anaerobic tent isolates to be indistinguishable, suggesting that they originated from a common source. Growth of the organism from patient samples was therefore regarded as potential contamination. Prior to this, six of the eight patients received antibiotics related to this positive culture and had Infectious Disease consultations. Providers of the patients were contacted regarding the contamination issue. The anaerobic tent manufacturer was consulted and ultimately recommended using Peridox Sporicidal Disinfectant. Six months later, the tent was re-sampled and did not yield positive cultures. Conclusion A pseudo-outbreak of the uncommon organism C. paraputrificum was related to insufficient disinfection practices of an anaerobic culture tent. This had negative effects on our institution and patient care in terms of cost, time, and unnecessary treatment. The use of sporicidal disinfectant has since proven effective to prevent contamination from spore-producing microbes. Disclosures All authors: No reported disclosures.

An estimated 4% of inpatients in U.S. acute care hospitals are diagnosed with preventable health care–associated infections (HAIs).1 Although concerted infection control efforts have achieved reductions in some HAIs,2 the prevalence of HAIs as a whole is growing. This rise in prevalence is occurring despite increasing efforts to improve infection control protocols and implement prevention measures.3 Research4,5 has shown that improvements in infection control and prevention are dependent not only on training health care workers (HCWs) to perform clinical techniques and apply administrative protocols but also on (1) the extent to which such practices are accepted by HCWs as useful or necessary and (2) the identification and removal of barriers to implementation. We argue that procedural approaches alone, even with high levels of adherence, are often insufficient to solve the growing problem of HAIs; it is equally important that interventions address themore complex cognitive aspects of HAI control and prevention. HCWs facemany patient care situations for which standard procedures have not been and cannot be developed. In these cases, HCWs must make decisions with incomplete information and a high degree of uncertainty; understand and balance risk versus reward; account for numerous demands, including those of patients, hospital administrators, and insurance providers; coordinate care across multiple contexts and caregivers; and exercise clinical judgment. To implement a reduction in HAIs therefore requires that HCWs follow infection control procedures but also make clinical decisions related to HAI prevention, and the former must be situated within the latter. This suggests that improvements in infection control education and training for HCWs are critical for reducing HAIs. In this commentary, our aim is to characterize and discuss the affordances of a novel approach to this problem based on cognitive simulation6-8: a practice-based intervention inwhich participants learn to solve multidimensional problems characterized by incomplete information, multiple stakeholders, and incommensurate demands. This approach, though as yet untried in the context of the complex arena of HAI prevention, has the potential to improve implementation of and adherence to infection control procedures and, more importantly, help HCWs learn to make clinical decisions that promote HAI control and prevention. There are, of course, many types of cognitive simulation in medical education,6,9-12 and they are used for a wide range of training purposes. According to a recent review by Satish et al,13 however, most cognitive simulations seek to replicate the challenges and demands of clinical practice, providing a safe setting for HCWs to rehearse skills, gain confidence, and develop their abilities in case management, critical thinking, decision-making, and other important aspects of professional practice. However, simulating day-today practice does not help HCWs understand the systemic aspects of the problem and the bigger picture of HAI prevention. * Address correspondence to Nasia Safdar, MD, PhD, Department of Medicine, Division of Infectious Disease, School of Medicine and Public Health, University of Wisconsin–Madison, 5138 Centennial Building, 1685 Highland Avenue, Madison, WI 53705. E-mail address: ns2@medicine.wisc.edu (N. Safdar). Funding/support: This work was funded in part by the National Science Foundation (DRL-0918409, DRL-0946372, DRL-1247262, DRL-1418288, DUE-0919347, DUE1225885, EEC-1232656, EEC-1340402, and REC-0347000), theMacArthur Foundation, the Spencer Foundation, the Wisconsin Alumni Research Foundation, and the Office of the Vice Chancellor for Research and Graduate Education at the University of Wisconsin–Madison. N.S. is supported by a Veterans Affairs–funded patient safety center and an R03 from AHRQ. Conflicts of interest: None to report. Disclaimer: The opinions, findings, and conclusions do not reflect the views of the funding agencies, cooperating institutions, or other individuals.

Increased smoking and a detrimental response to tobacco smoke in the lungs of HIV/AIDS patients result in an increased risk for COPD. We aimed to determine the predictive value of a COPD screening strategy validated in the general population and to identify HIV-related factors associated with decreased lung function. Subjects at least 35 years of age at an HIV clinic in New York City completed a COPD screening questionnaire and peak flow measurement. Those with abnormal results and a random one-third of normal screens had spirometry. 235 individuals were included and 89 completed spirometry. Eleven (12%) had undiagnosed airway obstruction and 5 had COPD. A combination of a positive questionnaire and abnormal peak flow yielded a sensitivity of 20% (specificity 93%) for detection of COPD. Peak flow alone had a sensitivity of 80% (specificity 80%). Abnormal peak flow was associated with an AIDS diagnosis (p=0.04), lower nadir (p=0.001), and current CD4 counts (p=0.001). Nadir CD4 remained associated in multivariate analysis (p=0.05). Decreased FEV1 (

IntroductionPrevention of multidrug-resistant organism (MDRO) infections, such as those caused by methicillin-resistantStaphylococcus aureus, vancomycin-resistant enterococci, fluoroquinolone-resistant Gram-negative bacteria andClostridium difficileis crucial. Evidence suggests that dietary fibre increases gut microbial diversity, which may help prevent colonisation and subsequent infection by MDROs. The aim of the Winning the War on Antibiotic Resistance (WARRIOR) project is to examine associations of dietary fibre consumption with the composition of the gut microbiota and gut colonisation by MDROs. The secondary purpose of the study is to create a biorepository of multiple body site specimens for future microbiota research.Methods and analysisThe WARRIOR project collects biological specimens, including nasal, oral and skin swabs and saliva and stool samples, along with extensive data on diet and MDRO risk factors, as an ancillary study of the Survey of the Health of Wisconsin (SHOW). The SHOW is a population-based health survey collecting data on several different health determinants and outcomes, as well as objective body measurements and biological specimens. WARRIOR participants include 600 randomly selected Wisconsin residents age 18 and over. Specimens are screened for MDRO colonisation and DNA is extracted for 16S ribosomal RNA-based microbiota sequencing. Data will be analysed to assess the relationship between dietary fibre, the gut microbiota composition and gut MDRO colonisation.Ethics and disseminationThe WARRIOR project is approved by the University of Wisconsin Institutional Review Board. The main results of this study will be published in a peer-reviewed scientific journal.

Smoking is common in patients with HIV and is associated with increased morbidity and mortality. With the goal of targeting future cessation interventions, we sought to identify factors associated with smoking status, readiness and confidence in cessation, and success in quitting. As part of a larger study in New York City assessing predictors of chronic obstructive pulmonary disease (COPD), we enrolled HIV-infected subjects at least 35 years of age without known asthma or COPD. Current smokers received detailed tobacco history, and smoking status was assessed by chart review at 3 and 6 months post-enrollment. Two hundred subjects were enrolled (29% current smokers, 31.5% never smokers, 39.5% former smokers, mean age of 49, 84% male, 64% had AIDS, and 97% were receiving antiretroviral therapy). Current smokers had higher unemployment and increased rates of other substance use than former smokers or never smokers. In multivariate analysis, being unemployed and having used inhalant drugs were associated with current smoking. Substance abuse history was not correlated with readiness to quit or patient estimated cessation. Lower education was associated with decreased readiness to quit. Follow-up smoking status for baseline current smokers was available for 47/58 enrollees at 6 months; 4 (9%) stopped smoking completely, and 17 (36%) decreased the number of packs-per-day. Smoking and concomitant substance abuse is common in HIV, and special attention should be given to this issue, in addition to a patient's readiness to quit, when implementing tobacco cessation protocols, especially in busy urban HIV care centers.

Tobacco smoking has many adverse health consequences. Patients with human immunodeficiency virus (HIV) infection smoke at very high rates, and many of the comorbidities associated with smoking in the general population are more prevalent in this population. It is likely that a combination of higher smoking rates along with an altered response to cigarette smoke throughout the body in persons with HIV infection leads to increased rates of the known conditions related to smoking. Several AIDS-defining conditions associated with smoking have been reviewed elsewhere. This review aims to summarize the data on non-AIDS-related health consequences of smoking in the HIV-infected population and explore evidence for the potential compounding effects on chronic systemic inflammation due to HIV infection and smoking.

This article was migrated. The article was not marked as recommended. With the world in the throes of the largest outbreak of Ebola Virus Disease (EVD) in history, many institutions in the United States have developed institutional policies and procedures for the screening, diagnosis and management of patients with EVD. Healthcare workers caring for these seriously ill patients are at high risk of contracting EVD through contact with blood and body fluids. With the exception of experimental therapeutics, treatment is largely supportive, requiring healthcare workers to have regular close contact with patients. Given the proportion of healthcare workers who have contracted EVD from patients and the high mortality rate, a central consideration has been whether healthcare trainees should be exempted from the direct care of patients with EVD. Educational needs and ethical issues are discussed. We provide arguments for and against this approach, and present a multifaceted framework that may be useful to institutions grappling with this issue.

A structured technique for software validation is discussed for the three major categories of software used in clinical trials systems: data capture, data management, and report generation. The technique emphasizes structured, modular software design; algorithmic validation; single-thread system design; and the use of database structures (including meta-data structures) to increase software reliability.