A multi-species outbreak of VIM-producing carbapenem-resistant bacteria in a burn unit and subsequent investigation of rapid development of cefiderocol resistance.

Carbapenem resistance due to metallo-ß-lactamases (MBLs) such as the Verona integron-encoded metallo-ß-lactamase (VIM) is particularly problematic due to the limited treatment options. We describe a case series of bacterial infections in a tertiary care hospital due to multi-species acquisition of a VIM gene along with our experience using novel ß-lactam antibiotics and antibiotic combinations to treat these infections. Four patients were treated with the combination of ceftazidime-avibactam and aztreonam, with no resistance to the combination detected. However, cefiderocol-resistant Klebsiella pneumoniae isolates were detected in two out of the five patients who received cefiderocol within 3 weeks of having started the antibiotic. Strain pairs of sequential susceptible and resistant isolates from both patients were analyzed using whole-genome sequencing. This analysis revealed that the pairs of isolates independently acquired point mutations in both the cirA and fiu genes, which encode siderophore receptors. These point mutations were remade in a laboratory strain of K. pneumoniae and resulted in a significant increase in the MIC of cefiderocol, even in the absence of a beta-lactamase enzyme or a penicillin-binding protein 3 (PBP3) mutation. While newer ß-lactam antibiotics remain an exciting addition to the antibiotic armamentarium, their use must be accompanied by diligent monitoring for the rapid development of resistance.

Rhizobium radiobacter pseudo-outbreak linked to tissue-processing contamination.

A cluster of Rhizobium radiobacter isolates isolated from six unique surgical tissue cultures prompted an investigation ultimately identifying a pseudo-outbreak linked to errant laboratory tissue processing with contaminated, nonsterile saline. Timely response and multidisciplinary collaboration led to tangible system-level interventions and avoidance of unnecessary antibiotic exposures.

Traditional definition of healthcare-associated influenza underestimates cases associated with other healthcare exposures in a population-based surveillance system.

OBJECTIVE: To provide comprehensive population-level estimates of the burden of healthcare-associated influenza. DESIGN: Retrospective cross-sectional study. SETTING: US Influenza Hospitalization Surveillance Network (FluSurv-NET) during 2012-2013 through 2018-2019 influenza seasons. PATIENTS: Laboratory-confirmed influenza-related hospitalizations in an 8-county catchment area in Tennessee. METHODS: The incidence of healthcare-associated influenza was determined using the traditional definition (ie, positive influenza test after hospital day 3) in addition to often underrecognized cases associated with recent post-acute care facility admission or a recent acute care hospitalization for a noninfluenza illness in the preceding 7 days. RESULTS: Among the 5,904 laboratory-confirmed influenza-related hospitalizations, 147 (2.5%) had traditionally defined healthcare-associated influenza. When we included patients with a positive influenza test obtained in the first 3 days of hospitalization and who were either transferred to the hospital directly from a post-acute care facility or who were recently discharged from an acute care facility for a noninfluenza illness in the preceding 7 days, we identified an additional 1,031 cases (17.5% of all influenza-related hospitalizations). CONCLUSIONS: Including influenza cases associated with preadmission healthcare exposures with traditionally defined cases resulted in an 8-fold higher incidence of healthcare-associated influenza. These results emphasize the importance of capturing other healthcare exposures that may serve as the initial site of viral transmission to provide more comprehensive estimates of the burden of healthcare-associated influenza and to inform improved infection prevention strategies.

Asymptomatic screening for severe acute respiratory coronavirus virus 2 (SARS-CoV-2) as an infection prevention measure in healthcare facilities: Challenges and considerations.

Testing of asymptomatic patients for severe acute respiratory coronavirus virus 2 (SARS-CoV-2) (ie, "asymptomatic screening) to attempt to reduce the risk of nosocomial transmission has been extensive and resource intensive, and such testing is of unclear benefit when added to other layers of infection prevention mitigation controls. In addition, the logistic challenges and costs related to screening program implementation, data noting the lack of substantial aerosol generation with elective controlled intubation, extubation, and other procedures, and the adverse patient and facility consequences of asymptomatic screening call into question the utility of this infection prevention intervention. Consequently, the Society for Healthcare Epidemiology of America (SHEA) recommends against routine universal use of asymptomatic screening for SARS-CoV-2 in healthcare facilities. Specifically, preprocedure asymptomatic screening is unlikely to provide incremental benefit in preventing SARS-CoV-2 transmission in the procedural and perioperative environment when other infection prevention strategies are in place, and it should not be considered a requirement for all patients. Admission screening may be beneficial during times of increased virus transmission in some settings where other layers of controls are limited (eg, behavioral health, congregate care, or shared patient rooms), but widespread routine use of admission asymptomatic screening is not recommended over strengthening other infection prevention controls. In this commentary, we outline the challenges surrounding the use of asymptomatic screening, including logistics and costs of implementing a screening program, and adverse patient and facility consequences. We review data pertaining to the lack of substantial aerosol generation during elective controlled intubation, extubation, and other procedures, and we provide guidance for when asymptomatic screening for SARS-CoV-2 may be considered in a limited scope.

Universal admission laboratory screening for severe acute respiratory coronavirus virus 2 (SARS-CoV-2) asymptomatic infection across a large health system.

BACKGROUND: Admission laboratory screening for asymptomatic coronavirus disease 2019 (COVID-19) has been utilized to mitigate healthcare-associated severe acute respiratory coronavirus virus 2 (SARS-CoV-2) transmission. An understanding of the impact of such testing across a variety of patient populations is needed. METHODS: SARS-CoV-2 nucleic acid amplification admission testing results for all asymptomatic patients across 4 distinct inpatient facilities between April 20, 2020, and June 14, 2021, were analyzed. Positivity rates and the number needed to test (NNT) to identify 1 asymptomatic infected patient were calculated. Admission results were compared to COVID-19 community incidence rates for the system's surrounding metropolitan service area. Using a national survey of hospital epidemiologists, a clinically meaningful NNT of 1:100 was identified. RESULTS: In total, 51,187 tests were collected (positivity rate, 1.8%). During periods of high transmission, the NNT met the clinically relevant threshold in all populations. The NNT approached or met the threshold for most locations during periods of lower transmission. For all transmission levels, the NNT for fully vaccinated patients did not meet the threshold. CONCLUSIONS: Implementing an asymptomatic patient admission testing program can provide clinically relevant data based on the NNT, even during periods of lower transmission and among different patient populations. Limiting admission testing to non-fully vaccinated patients during periods of lower transmission may be a strategy to address resource concerns around this practice. Although the impact of such testing on healthcare-associated COVID-19 among patients and healthcare workers could not be clearly determined, these data provide important information as facilities weigh the costs and benefits of such testing.

Identifying barriers to compliance with a universal inpatient protocol for Staphylococcus aureus nasal decolonization with povidone-iodine.

Academic hospital nurses were surveyed to assess adherence barriers to a universal povidone-iodine nasal decolonization protocol to prevent Staphylococcus aureus infection. Low training rates, inadequate supplies, documentation and tracking challenges, patient refusal, and burnout contributed to suboptimal adherence. Prioritizing education is essential but alone is insufficient for successful protocol adoption.

Approaches to healthcare personnel exemption requests from coronavirus disease 2019 (COVID-19) vaccination: Results of a national survey.

OBJECTIVE: Although a growing number of healthcare facilities are implementing healthcare personnel (HCP) coronavirus disease 2019 (COVID-19) vaccination requirements, vaccine exemption request management as a part of such programs is not well described. DESIGN: Cross-sectional survey. PARTICIPANTS: Infectious disease (ID) physician members of the Emerging Infections Network with infection prevention or hospital epidemiology responsibilities. METHODS: Eligible persons were sent a web-based survey focused on hospital plans and practices around exemption allowances from HCP COVID-19 vaccine requirements. RESULTS: Of the 695 ID physicians surveyed, 263 (38%) responded. Overall, 160 respondent institutions (92%) allowed medical exemptions, whereas 132 (76%) allowed religious exemptions. In contrast, only 14% (n = 24) allowed deeply held personal belief exemptions. The types of medical exemptions allowed varied considerably across facilities, with allergic reactions to the vaccine or its components accepted by 145 facilities (84%). For selected scenarios commonly used as the basis for religious and deeply held personal belief exemption requests, 144 institutions (83%) would not approve exemptions focused on concerns regarding right of consent or violations of freedom of personal choice, and 140 institutions (81%) would not approve exemptions focused on introducing foreign substances into one's body or the sanctity of the body. Most respondents noted plans for additional infection prevention interventions for HCP who received an exemption for COVID-19 vaccination. CONCLUSIONS: Although many respondent institutions allowed exemptions from HCP COVID-19 vaccination requirements, the types of exemptions allowed and how the exemption programs were structured varied widely.

Coronavirus disease 2019 (COVID-19) vaccination preparedness policies in US hospitals.

We surveyed infectious disease specialists about early coronavirus disease 2019 (COVID-19) vaccination preparedness. Almost all responding institutions rated their facility's preparedness plan as either excellent or adequate. Vaccine hesitancy and concern about adverse reactions were the most commonly anticipated barriers to COVID-19 vaccination. Only 60% believed that COVID-19 vaccination should be mandatory.

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

This SHEA white paper identifies knowledge gaps and challenges in healthcare epidemiology research related to coronavirus disease 2019 (COVID-19) with a focus on core principles of healthcare epidemiology. These gaps, revealed during the worst phases of the COVID-19 pandemic, are described in 10 sections: epidemiology, outbreak investigation, surveillance, isolation precaution practices, personal protective equipment (PPE), environmental contamination and disinfection, drug and supply shortages, antimicrobial stewardship, healthcare personnel (HCP) occupational safety, and return to work policies. Each section highlights three critical healthcare epidemiology research questions with detailed description provided in supplementary materials. This research agenda calls for translational studies from laboratory-based basic science research to well-designed, large-scale studies and health outcomes research. Research gaps and challenges related to nursing homes and social disparities are included. Collaborations across various disciplines, expertise and across diverse geographic locations will be critical.

Health Care-Acquired Viral Respiratory Diseases.

Health care-acquired viral respiratory infections are common and cause increased patient morbidity and mortality. Although the threat of viral respiratory infection has been underscored by the coronavirus disease 2019 (COVID-19) pandemic, respiratory viruses have a significant impact in health care settings even under normal circumstances. Studies report decreased nosocomial transmission when aggressive infection control measures are implemented, with more success noted when using a multicomponent approach. Influenza vaccination of health care personnel furthers decrease rates of transmission; thus, mandatory vaccination is becoming more common. This article discusses the epidemiology, transmission, and control of health care-associated respiratory viral infections.

Characteristics of Inpatient Units Associated With Sustained Hand Hygiene Compliance.

OBJECTIVES: Following institution of a hand hygiene (HH) program at an academic medical center, HH compliance increased from 58% to 92% for 3 years. Some inpatient units modeled early, sustained increases, and others exhibited protracted improvement rates. We examined the association between patterns of HH compliance improvement and unit characteristics. METHODS: Adult inpatient units (N = 35) were categorized into the following three tiers based on their pattern of HH compliance: early adopters, nonsustained and late adopters, and laggards. Unit-based culture measures were collected, including nursing practice environment scores (National Database of Nursing Quality Indicators [NDNQI]), patient rated quality and teamwork (Hospital Consumer Assessment of Healthcare Provider and Systems), patient complaint rates, case mix index, staff turnover rates, and patient volume. Associations between variables and the binary outcome of laggard (n = 18) versus nonlaggard (n = 17) were tested using a Mann-Whitney U test. Multivariate analysis was performed using an ordinal regression model. RESULTS: In direct comparison, laggard units had clinically relevant differences in NDNQI scores, Hospital Consumer Assessment of Healthcare Provider and Systems scores, case mix index, patient complaints, patient volume, and staff turnover. The results were not statistically significant. In the multivariate model, the predictor variables explained a significant proportion of the variability associated with laggard status, (R2 = 0.35, P = 0.0481) and identified NDNQI scores and patient complaints as statistically significant. CONCLUSIONS: Uptake of an HH program was associated with factors related to a unit's safety culture. In particular, NDNQI scores and patient complaint rates might be used to assist in identifying units that may require additional attention during implementation of an HH quality improvement program.

Policy statement from the Society for Healthcare Epidemiology of America (SHEA): Only medical contraindications should be accepted as a reason for not receiving all routine immunizations as recommended by the Centers for Disease Control and Prevention.

SHEA endorses adhering to the recommendations by the CDC and ACIP for immunizations of all children and adults. All persons providing clinical care should be familiar with these recommendations and should routinely assess immunization compliance of their patients and strongly recommend all routine immunizations to patients. All healthcare personnel (HCP) should be immunized against vaccine-preventable diseases as recommended by the CDC/ACIP (unless immunity is demonstrated by another recommended method). SHEA endorses the policy that immunization should be a condition of employment or functioning (students, contract workers, volunteers, etc) at a healthcare facility. Only recognized medical contraindications should be accepted for not receiving recommended immunizations.

Use of a comprehensive program to review religious and personal seasonal influenza vaccination exemption requests by healthcare personnel.

OBJECTIVE: Vanderbilt University Medical Center (VUMC) requires that all faculty and staff receive the seasonal influenza vaccine annually or receive an approved vaccine exemption, either for a medical or deeply held religious or personal belief. We sought to understand the underlying principles behind these exemption requests and their interaction with a multidisciplinary exemption review process. DESIGN: All of the personal and religious exemption requests at VUMC for 3 consecutive influenza seasons from 2015 to 2018 were analyzed, categorizing these requests by 1 of 12 standardized employee categories and 1 of 18 unique reasons for vaccine exemption. SETTING: Tertiary-care academic medical center. PARTICIPANTS: Healthcare personnel (HCP). RESULTS: Among the 3 influenza seasons, 1.1%-2.1% of all VUMC HCP requested religious or personal exemption from vaccination. The frequency of religious and personal exemption approval increased annually from 296 of 452 (65.5%) to 196 of 248 (80.2%) to 283 of 323 (87.6%) over the 3 seasons, representing a statistically significant increase each year. Of the 5 most common reasons against vaccination, 4 were explicitly religious in nature; the most common reason was that the "body is a temple or sacred." Nonclinical staff submitted the most religious and personal exemption requests of any job category, submitting approximately one-third of all requests every year. CONCLUSIONS: These results demonstrate how detailed the personal or religious convictions behind vaccine avoidance can be among HCP and how vaccine avoidance stems from much more than simple misinformation regarding vaccination. The intersection between misinformation and personal or religious beliefs provides a unique opportunity to address HCP opinions toward vaccination in an exemption and appeals process like the one described here.

Expanding mandatory healthcare personnel immunization beyond influenza: Impact of a broad immunization program with enhanced accountability.

OBJECTIVE: Evaluation of a mandatory immunization program to increase and sustain high immunization coverage for healthcare personnel (HCP). DESIGN: Descriptive study with before-and-after analysis. SETTING: Tertiary-care academic medical center. PARTICIPANTS: Medical center HCP. METHODS: A comprehensive mandatory immunization initiative was implemented in 2 phases, starting in July 2014. Key facets of the initiative included a formalized exemption review process, incorporation into institutional quality goals, data feedback, and accountability to support compliance. RESULTS: Both immunization and overall compliance rates with targeted immunizations increased significantly in the years after the implementation period. The influenza immunization rate increased from 80% the year prior to the initiative to >97% for the 3 subsequent influenza seasons (P < .0001). Mumps, measles and varicella vaccination compliance increased from 94% in January 2014 to >99% by January 2017, rubella vaccination compliance increased from 93% to 99.5%, and hepatitis B vaccination compliance from 95% to 99% (P < .0001 for all comparisons). An associated positive effect on TB testing compliance, which was not included in the mandatory program, was also noted; it increased from 76% to 92% over the same period (P < .0001). CONCLUSIONS: Thoughtful, step-wise implementation of a mandatory immunization program linked to professional accountability can be successful in increasing immunization rates as well as overall compliance with policy requirements to cover all recommended HCP immunizations.

Assessing coronavirus disease 2019 (COVID-19) transmission to healthcare personnel: The global ACT-HCP case-control study.

OBJECTIVE: To characterize associations between exposures within and outside the medical workplace with healthcare personnel (HCP) SARS-CoV-2 infection, including the effect of various forms of respiratory protection. DESIGN: Case-control study. SETTING: We collected data from international participants via an online survey. PARTICIPANTS: In total, 1,130 HCP (244 cases with laboratory-confirmed COVID-19, and 886 controls healthy throughout the pandemic) from 67 countries not meeting prespecified exclusion (ie, healthy but not working, missing workplace exposure data, COVID symptoms without lab confirmation) were included in this study. METHODS: Respondents were queried regarding workplace exposures, respiratory protection, and extra-occupational activities. Odds ratios for HCP infection were calculated using multivariable logistic regression and sensitivity analyses controlling for confounders and known biases. RESULTS: HCP infection was associated with non-aerosol-generating contact with COVID-19 patients (adjusted OR, 1.4; 95% CI, 1.04-1.9; P = .03) and extra-occupational exposures including gatherings of ≥10 people, patronizing restaurants or bars, and public transportation (adjusted OR range, 3.1-16.2). Respirator use during aerosol-generating procedures (AGPs) was associated with lower odds of HCP infection (adjusted OR, 0.4; 95% CI, 0.2-0.8, P = .005), as was exposure to intensive care and dedicated COVID units, negative pressure rooms, and personal protective equipment (PPE) observers (adjusted OR range, 0.4-0.7). CONCLUSIONS: COVID-19 transmission to HCP was associated with medical exposures currently considered lower-risk and multiple extra-occupational exposures, and exposures associated with proper use of appropriate PPE were protective. Closer scrutiny of infection control measures surrounding healthcare activities and medical settings considered lower risk, and continued awareness of the risks of public congregation, may reduce the incidence of HCP infection.

Use of airborne infection isolation in potential cases of pulmonary tuberculosis.

OBJECTIVE: To identify risk factors of patients placed in airborne infection isolation (AII) for possible pulmonary tuberculosis (TB) to better predict TB diagnosis and allow more judicious use of AII. METHODS: Case-control, retrospective study at a single tertiary-care academic medical center. The study included all adult patients admitted from October 1, 2014, through October 31, 2017, who were placed in AII for possible pulmonary TB. Cases were defined as those ultimately diagnosed with pulmonary TB. Controls were defined as those not diagnosed with pulmonary TB. Those with TB diagnosed prior to admission were excluded. In total, 662 admissions (558 patients) were included. RESULTS: Overall, 15 cases of pulmonary TB were identified (2.7%); of these, 2 were people living with human immunodeficiency virus (HIV; PLWH). Statistical analysis was limited by low case number. Those diagnosed with pulmonary TB were more likely to have been born outside the United States (53% vs 13%; P < .001) and to have had prior positive TB testing, regardless of prior treatment (50% vs 19%; P = .015). A multivariate analysis using non-US birth and prior positive TB testing predicted an 18.2% probability of pulmonary TB diagnosis when present, compared with 1.0% if both factors were not present. CONCLUSIONS: The low number of pulmonary TB cases indicated AII overuse, especially in PLWH, and more judicious use of AII is warranted. High-risk groups, including those born outside the United States and those with prior positive TB testing, should be considered for AII in the appropriate clinical setting.

Reducing inappropriate urine cultures through a culture standardization program.

BACKGROUND: The objective of this study was to evaluate the impact of a urine culture standardization program that included order indications and urinalysis (U/A) with reflexive culture. The program applied to all adult and pediatric inpatients at an academic medical center; emergency department and ambulatory clinic patients were excluded. METHODS: The analysis compared outcomes in the pre-implementation (January 2015-May 2016) and post-implementation (July 2016-September 2017) periods. The primary outcomes were urine culture and U/A orders per 1,000 patient days, catheter-associated urinary tract infection (CAUTI) rate per 1,000 catheter days, and urine culture contamination rate per 1,000 patient days. Catheter standardized utilization ratios (SURs) were also examined. RESULTS: The intervention was associated with a significant decrease in urine culture rates by 6.9 cultures per 1,000 patient days (95% CI -4.44, -9.44; P < .0001). The U/A testing rate per 1,000 patient days significantly increased pre-intervention, was not affected acutely by the intervention institution, and significantly decreased post-implementation. The CAUTI rate was not significantly changed by the intervention but did significantly increase post-implementation by 0.2 per 1,000 catheter days (95% CI 0.01, 0.47; P = .04); SURs significantly decreased (0.03; 95% CI -0.003, -0.05; P = .03); and the urine culture contamination rate per month showed no significant change. Sixty-four percent of urine cultures ordered using the reflexive test did not reflex to culture by U/A criteria. CONCLUSIONS: A urine culture standardization program led to a significant reduction in urine cultures and did not lead to an increase in U/A testing rates. CAUTI rates increased post-implementation, which may have been confounded by reduced catheter utilization.

A Process for Assessing Products for Infection Prevention in Health Care Settings: A Framework From the Healthcare Infection Control Practices Advisory Committee of the Centers for Disease Control and Prevention.

Infection control is a complex task that spans people, products, and practices in diverse settings. For years, the Healthcare Infection Control Practices Advisory Committee (HICPAC) has provided advice and guidance to the Centers for Disease Control and Prevention (CDC) on how best to prevent infections. These recommendations have focused largely on health care delivery practices and occasionally on general categories of products. With an influx of novel infection control products and growing use of these products by frontline clinicians, an efficient process for developing transparent, rigorous product recommendations that includes myriad data sources was necessary. To address this gap, the CDC asked HICPAC to develop a process that would help inform committees considering product-related recommendations. This article describes the process to develop this approach and provides an outline of how the tool may be used when products with infection control claims are recommended in guidelines or recommendations for infection prevention.