SARS-CoV-2 Exposure Investigations Using Genomic Sequencing Among Healthcare Workers and Patients in A Large Academic Center.

SARS-CoV-2 transmissions among healthcare personnel (HCP) and hospitalized patients are challenging to confirm. Investigation of infected persons often reveals multiple potential risk factors for viral acquisition. We combined exposure investigation with genomic analysis confirming two hospital-based clusters. Prolonged close contact with unmasked, unrecognized infectious, individuals was a common risk.

Principles of diagnostic stewardship: A practical guide from the Society for Healthcare Epidemiology of America Diagnostic Stewardship Task Force.

We provide an overview of diagnostic stewardship with key concepts that include the diagnostic pathway and the multiple points where interventions can be implemented, strategies for interventions, the importance of multidisciplinary collaboration, and key microbiologic diagnostic tests that should be considered for diagnostic stewardship. The document focuses on microbiologic laboratory testing for adult and pediatric patients and is intended for a target audience of healthcare workers involved in diagnostic stewardship interventions and all workers affected by any step of the diagnostic pathway (ie, ordering, collecting, processing, reporting, and interpreting results of a diagnostic test). This document was developed by the Society for Healthcare Epidemiology of America Diagnostic Stewardship Taskforce.

Impact of weekly asymptomatic testing for severe acute respiratory coronavirus virus 2 (SARS-CoV-2) in inpatients at an academic hospital.

We analyzed the impact of a 7-day recurring asymptomatic SARS-CoV-2 testing protocol for all patients hospitalized at a large academic center. Overall, 40 new cases were identified, and 1 of 3 occurred after 14 days of hospitalization. Recurring testing can identify unrecognized infections, especially during periods of elevated community transmission.

From alpha to omicron: a radiation oncology network's biocontainment-based COVID-19 response experience.

Background and purpose: : To develop the safest possible environment for treating urgent COVID+ patients, we describe the unique construction of negative air pressure CT simulator and treatment vaults in addition to screening, delay and treatment protocols and their evolution over the course of the COVID pandemic. Materials and methods: Construction of large HEPA filter air flow systems into existing ductwork in CT simulator rooms and photon and proton treatment vaults was attempted to create negative pressure rooms. An asymptomatic COVID screening protocol was implemented for all patients prior to initiation of treatment. Patients could undergo simulation and/or treatment in the biocontainment environments according to a predefined priority scale and protocol. Patients treated under the COVID-19 protocol from 6/2020 to 1/2022 were retrospectively reviewed. Results: Negative airflow environments were created across a regional network, including a multi-gantry proton therapy unit. In total, 6525 patients were treated from 6/2020 through 1/2022 across 5 separate centers. The majority of COVID positive patients had treatment deferred when deemed safe. A total of 42 COVID positive patients who were at highest risk were treated under the COVID-19 biocontainment protocol, in contrast to those who were placed on treatment break. For 61.9% of patients, these safety measures mitigated an extended break during treatment. The majority (64.3%) of patients were treated with curative intent. The median number of biocontainment sessions required by each patient was 6 (range: 1-15), prior to COVID clearance and resumption of treatment in a normal air flow environment. Conclusion: Constructing negative pressure environments and developing a COVID-19 biocontainment treatment protocol allowed for the safe treatment of COVID positive radiation oncology patients within our department and strengthens future biopreparedness. These biocontainment units set a high standard of safety in radiation oncology during the current or for any future infectious outbreak.

From alpha to omicron: a radiation oncology network's biocontainment-based COVID-19 response experience

Background and purpose : To develop the safest possible environment for treating urgent COVID+ patients, we describe the unique construction of negative air pressure CT simulator and treatment vaults in addition to screening, delay and treatment protocols and their evolution over the course of the COVID pandemic. Materials and methods Construction of large HEPA filter air flow systems into existing ductwork in CT simulator rooms and photon and proton treatment vaults was attempted to create negative pressure rooms. An asymptomatic COVID screening protocol was implemented for all patients prior to initiation of treatment. Patients could undergo simulation and/or treatment in the biocontainment environments according to a predefined priority scale and protocol. Patients treated under the COVID-19 protocol from 6/2020 to 1/2022 were retrospectively reviewed. Results Negative airflow environments were created across a regional network, including a multi-gantry proton therapy unit. In total, 6525 patients were treated from 6/2020 through 1/2022 across 5 separate centers. The majority of COVID positive patients had treatment deferred when deemed safe. A total of 42 COVID positive patients who were at highest risk were treated under the COVID-19 biocontainment protocol, in contrast to those who were placed on treatment break. For 61.9% of patients, these safety measures mitigated an extended break during treatment. The majority (64.3%) of patients were treated with curative intent. The median number of biocontainment sessions required by each patient was 6 (range: 1-15), prior to COVID clearance and resumption of treatment in a normal air flow environment. Conclusion Constructing negative pressure environments and developing a COVID-19 biocontainment treatment protocol allowed for the safe treatment of COVID positive radiation oncology patients within our department and strengthens future biopreparedness. These biocontainment units set a high standard of safety in radiation oncology during the current or for any future infectious outbreak.

The role of procalcitonin results in antibiotic decision-making in coronavirus disease 2019 (COVID-19).

OBJECTIVE: To evaluate the role of procalcitonin (PCT) results in antibiotic decisions for COVID-19 patients at hospital presentation. DESIGN, SETTING, AND PARTICIPANTS: Multicenter retrospective observational study of patients ≥18 years hospitalized due to COVID-19 at the Johns Hopkins Health system. Patients who were transferred from another facility with >24 hours stay and patients who died within 48 hours of hospitalization were excluded. METHODS: Elevated PCT values were determined based on each hospital's definition. Antibiotic therapy and PCT results were evaluated for patients with no evidence of bacterial community-acquired pneumonia (bCAP) and patients with confirmed, probable, or possible bCAP. The added value of PCT testing to clinical criteria in detecting bCAP was evaluated using receiving operating curve characteristics (ROC). RESULTS: Of 962 patients, 611 (64%) received a PCT test. ROC curves for clinical criteria and clinical criteria plus PCT test were similar (at 0.5 ng/mL and 0.25 ng/mL). By bCAP group, median initial PCT values were 0.58 ng/mL (interquartile range [IQR], 0.24-1.14), 0.23 ng/mL (IQR, 0.1-0.63), and 0.15 ng/mL (IQR, 0.09-0.35) for proven/probable, possible, and no bCAP groups, respectively. Among patients without bCAP, an elevated PCT level was associated with 1.8 additional days of CAP therapy (95% CI, 1.01-2.75; P < .01) compared to patients with a negative PCT result after adjusting for potential confounders. Duration of CAP therapy was similar between patients without a PCT test ordered and a low PCT level for no bCAP and possible bCAP groups. CONCLUSIONS: PCT results may be abnormal in COVID-19 patients without bCAP and may result in receipt of unnecessary antibiotics.

Development of an antimicrobial stewardship module in an electronic health record: Options to enhance daily antimicrobial stewardship activities.

PURPOSE: The purpose of this manuscript is to describe our experience developing an antimicrobial stewardship (AS) module as a clinical decision support tool in the Epic electronic health record (EHR). SUMMARY: Clinical decision support systems within the EHR can be used to decrease use of broad-spectrum antibiotics, improve antibiotic selection and dosing, decrease adverse effects, reduce antibiotic costs, and reduce the development of antibiotic resistance. The Johns Hopkins Hospital constructed an AS module within Epic. Customized stewardship alerts and scoring systems were developed to triage patients requiring stewardship intervention. This required a multidisciplinary approach with a team comprising AS physicians and pharmacists and Epic information technology personnel, with assistance from clinical microbiology and infection control when necessary. In addition, an intervention database was enhanced with stewardship-specific interventions, and workbench reports were developed specific to AS needs. We herein review the process, advantages, and challenges associated with the development of the Epic AS module. CONCLUSION: Customizing an AS module in an EHR requires significant time and expertise in antimicrobials; however, AS modules have the potential to improve the efficiency of AS personnel in performing daily stewardship activities and reporting through a single system.

Hospital-acquired infections among adult patients admitted for coronavirus disease 2019 (COVID-19).

In a multicenter cohort of 963 adults hospitalized due to coronavirus disease 2019 (COVID-19), 5% had a proven hospital-acquired infection (HAI) and 21% had a proven, probable, or possible HAI. Risk factors for proven or probable HAIs included intensive care unit admission, dexamethasone use, severe COVID-19, heart failure, and antibiotic exposure upon admission.

To Test, Perchance to Diagnose: Practical Strategies for Severe Acute Respiratory Syndrome Coronavirus 2 Testing.

Testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in symptomatic and asymptomatic patients is an important component of the multifaceted approach of managing the coronavirus disease 2019 pandemic. Determining how to best define testing strategies for different populations and incorporating these into broader infection prevention programs can be complex. Many circumstances are not addressed by federal, local, or professional guidelines. This commentary describes various scenarios in which testing of symptomatic or asymptomatic individuals for SARS-CoV-2 virus (antigen or ribonucleic acid) can be of potential benefit. Consideration to pretest probability, risks of testing (impact of false-positive or false-negative results), testing strategy, as well as action based on test results are explored. Testing, regardless of setting, must be incorporated into overarching infection control plans, which include use of personal protective equipment (eg, masks), physically distancing, and isolation when exposure is suspected.

Prevalence of Co-infection at the Time of Hospital Admission in COVID-19 Patients, A Multicenter Study.

BACKGROUND: Bacterial infections may complicate viral pneumonias. Recent reports suggest that bacterial co-infection at time of presentation is uncommon in coronavirus disease 2019 (COVID-19); however, estimates were based on microbiology tests alone. We sought to develop and apply consensus definitions, incorporating clinical criteria to better understand the rate of co-infections and antibiotic use in COVID-19. METHODS: A total of 1016 adult patients admitted to 5 hospitals in the Johns Hopkins Health System between March 1, 2020, and May 31, 2020, with COVID-19 were evaluated. Adjudication of co-infection using definitions developed by a multidisciplinary team for this study was performed. Both respiratory and common nonrespiratory co-infections were assessed. The definition of bacterial community-acquired pneumonia (bCAP) included proven (clinical, laboratory, and radiographic criteria plus microbiologic diagnosis), probable (clinical, laboratory, and radiographic criteria without microbiologic diagnosis), and possible (not all clinical, laboratory, and radiographic criteria met) categories. Clinical characteristics and antimicrobial use were assessed in the context of the consensus definitions. RESULTS: Bacterial respiratory co-infections were infrequent (1.2%); 1 patient had proven bCAP, and 11 (1.1%) had probable bCAP. Two patients (0.2%) had viral respiratory co-infections. Although 69% of patients received antibiotics for pneumonia, the majority were stopped within 48 hours in patients with possible or no evidence of bCAP. The most common nonrespiratory infection was urinary tract infection (present in 3% of the cohort). CONCLUSIONS: Using multidisciplinary consensus definitions, proven or probable bCAP was uncommon in adults hospitalized due to COVID-19, as were other nonrespiratory bacterial infections. Empiric antibiotic use was high, highlighting the need to enhance antibiotic stewardship in the treatment of viral pneumonias.