We aim to highlight the risks of acquiring carbapenemase-producing Enterobacterales (CPE) resistance genes in patients with severe coronavirus disease 2019 (COVID-19) in intensive care.

Outbreak analysis to assess for a transmission risk area (TRA) conducted after identification of potential CPE outbreak within shared room spaces in intensive care.

Analysis conducted within a 24-bed single-room model intensive-care department within a level-3 tertiary center public hospital in regional Victoria, Australia.

3 patients, with severe COVID-19 admitted to intensive care over a 3-month period with shared room spaces requiring prolonged mechanical ventilation and broad-spectrum antimicrobials, identified and were managed for CPE isolated from sputum. Overlap carbapenemase genes were identified among different organisms raising suspicion of transmitted resistance genes. A subsequent case managed for severe community-acquired pneumonia isolated CPE 3 months beyond these cases.

Outbreak analysis via weekly cross-sectional point prevalence screening of fecal samples or rectal swabs for CPE from patients admitted to the intensive-care department over a 4-week period.

34 patients were included in the analysis with 51 tests for CPE screening conducted. No further cases of CPE were identified. Statewide Infection Surveillance team and the Department of Health and Human Services did not find the cases to derive from a TRA. No further action including environmental screening was indicated.

These cases highlight the independent acquisition of CPE genes in patients with severe COVID-19 and antimicrobial selective pressures resulting in significant morbidity and mortality. Increasing awareness, robust antimicrobial stewardship, and infection prevention measures could reduce pressures driving CPE resistance mutations and the risk of CPE transmission.

To describe antimicrobial usage (AMU) trends before and during the coronavirus disease 2019 (COVID-19) pandemic, between COVID-19 and non-COVID-19 wards, and if there was any association with a COVID-19 order set.

Quasi-experimental retrospective interrupted time series analysis of AMU rates with a contemporaneous comparison of COVID-19 versus non-COVID-19 control wards. Analysis using incidence rate ratios (IRR) was conducted using a Poisson regression generalized linear model.

Five COVID-19 and 4 comparable non-COVID-19 wards and 6 intensive care units (ICUs) at 4 hospitals during pandemic waves 1–4.

All inpatients receiving systemic antimicrobials.

The COVID-19 checkbox antimicrobial order set was implemented in March 2020, to be used only if considered clinically indicated with modification in August 2021.

The primary outcome was a change in AMU rates (defined daily dose per 100 patient days per month) comparing pre- versus peri-pandemic periods and COVID-19 versus control non-COVID-19 wards. Secondary outcomes included antifungal usage rate in ICUs and assessing AMUs following implementation and modification of a COVID-19 order set.

Significantly greater rates of AMU (IRR[95%CI]) were observed on COVID-19 wards versus non-COVID-19 wards during waves 1–4 for all systemic antimicrobials (1.76[1.71–1.81], 1.10[1.07–1.13], 1.48[1.43–1.53], and 1.06[1.03–1.09]); for azithromycin (11.76[9.80–14.23], 10.96[9.49–12.74], 12.41[10.73–14.45], and 4.88[4.31–5.55]); and for ceftriaxone (2.39[2.16–2.65], 3.64[3.29–4.03], 2.94[2.67–3.23], and 1.62[1.49–1.76]).

We observed significantly increased AMU rates of all systemic agents during the first 4 waves of the pandemic and on COVID-19 wards compared with control wards for azithromycin and ceftriaxone. These agents saw a twofold reduction following order-set removal, suggesting that the clinical decision-support tool order set, as utilized, had influenced prescribing behavior.

We sought to compare patient outcomes between carbapenem-resistant Enterobacterales (CRE) and carbapenem-susceptible Enterobacterales (CSE) infections at our academic medical center.

We conducted a retrospective cohort study of adult patients with a positive culture of E. coli, E. cloacae, K. aerogenes, K. oxytoca, and/or K. pneumoniae admitted at UK HealthCare (January 1, 2010–December 31, 2019). Based on the type of pathogen on the date of the first culture (index date), patients were included in the CRE (i.e., exposed) group, or the CSE (comparator) group. Exclusion criteria were age < 18 years old, pregnancy, endocarditis, osteomyelitis, necrotizing fasciitis, or cystic fibrosis. We evaluated the impact of CRE vs CSE on a composite outcome of 30-day of all-cause mortality or discharge to hospice using Kaplan–Meier survival curves and Cox proportional hazard regression with inverse probability of treatment weights (IPTW).

Of 17,839 hospitalized patients, 128 and 6,953 patients were included in the CRE and CSE groups, respectively. Baseline differences existed in sex-assigned-at-birth, admission source, time-to-index culture, and infection type/severity. Most CRE index cultures observed (76%) only exhibited resistance to ertapenem. IPTW-adjusted HR [95% CI] of composite outcome was 0.99 [0.65, 1.51] after 30 days. Follow-up analysis in patients with carbapenem-non-susceptible Enterobacteralesbloodstream infections on index yielded an HR of 1.38 [0.85, 2.24].

Risk of composite outcome was not estimated to differ between patients with CRE and CSE in the overall analysis. Although follow-up analysis identified an increased risk, we cannot statistically distinguish this from a null effect.

We evaluated SARS-CoV-2 anti-nucleocapsid (anti-N) seroconversion and seroreversion rates, risk factors associated with SARS-CoV-2 seroconversion, and COVID-19 risk perceptions among academic healthcare center employees in a rural state.

Among employees aged ≥18 years who completed a screening survey (n = 1,377), we invited all respondents reporting previous COVID-19 (n = 85; 82 accepted) and a random selection of respondents not reporting previous COVID-19 (n = 370; 220 accepted) to participate. Participants completed surveys and provided blood samples at 3-month intervals (T0, T3, T6, T9). We used logistic regression to identify risk factors for seropositivity at T0.

The cohort was primarily direct patient caregivers (205/302; 67.9%), white (278/302; 92.1%), and female (212/302; 70.2%). At T0, 86/302 (28.4%) participants were seropositive. Of the seronegative participants, 6/198 (3.0%), 6/183 (3.3%), and 14/180 (7.8%) had seroconverted at T3, T6, and T9, respectively. The overall seroreversion rate was 6.98% at T9. At T0, nursing staff (odds ratio [OR], 2.37; 95% confidence interval [CI], 1.08, 5.19) and being within six feet of a non-household member outside of work (OR, 2.91; 95% CI, 1.02, 8.33) had significantly higher odds of seropositivity. Vaccination (OR, 0.05; 95% CI, 0.02, 0.12) and face mask use (OR, 0.36; 95% CI, 0.17, 0.78) were protective.

The seroconversion and seroreversion rates were low among participants. Public health and infection prevention measures implemented early in the COVID-19 pandemic – vaccination, face mask use, and social distancing – were associated with significantly lower odds of SARS-CoV-2 seropositivity among participants.

Improving the hospital environment and developing novel disinfection strategies are critical for infection control in healthcare settings. In this study, we explored the effects of electrochromic (EC) windows on indoor and patient microbiome in an inpatient hospital.

Hematology-Oncology patients at the University of Vermont Medical Center

We conducted a prospective study in ten occupied patient rooms. Five of the patient rooms had active EC windows that tint dynamically to control for heat and glare, and the other five rooms had deactivated EC windows that simulated traditional windows and blinds. Samples were collected one day before patient admission as baseline and on the 1st, 3rd, and 5th day of the patient stay. Total bacterial abundance and bacterial community structure were determined through quantitative PCR and 16s rRNA Illumina MiSeq sequencing, respectively.

Patient rooms with active EC windows had significantly lower light intensity and temperature than traditional patient rooms with blinds. The absolute bacterial abundance and diversities on windows were significantly lower in rooms with EC windows and the bacterial composition changed after one day EC window activation. Compared to baseline, relative abundance of the Staphylococcus genus was significantly lower on EC window surface during the five-day experiment. In contrast, the air microbiome was more diverse in rooms with EC windows.

Active electrochromic (EC) windows in patient rooms result in lower light intensity and temperature, reduced bacterial abundance and diversities on window surfaces, and a more diverse air microbiome, informing future healthcare design.

To evaluate the appropriateness of empiric initiation of meropenem in the intensive care unit (ICU) and to determine the agreement between internal medicine (IM) residents and infectious diseases (ID) physicians/pharmacists on appropriateness.

Retrospective observational study.

ICU in a tertiary care community teaching hospital.

Adult patients admitted to the ICU and started empirically on meropenem between April 1 and October 31, 2021.

Meropenem usage was categorized as appropriate or inappropriate according to criteria developed from previously published indications and modified by ID physicians/pharmacists to reflect local practices. Two investigators (an IM resident and either an ID physician or pharmacist) assessed the appropriateness, with a second ID physician resolving any disagreements. Inter-rater reliability was measured using the kappa statistic.

Ninety-seven participants were enrolled, with a mean age of 68 (SD, 17.0) years. Pneumonia was the most common infection (30.9%). Among the participants, 92.8% received an ID consultation, with 55.6% of these occurring before meropenem initiation. IM residents deemed 56.7% of meropenem administrations appropriate, whereas an ID physician/pharmacist deemed only 48.5% appropriate, agreeing on 79.4% of cases (kappa statistic 0.59, P <.001). After a third reviewer’s assessment was included, agreement between the resident and at least one of the two reviewers reached 90.7% (kappa 0.81, P <.001).

Approximately half of empiric meropenem started in the ICU was deemed inappropriate using institution-specific criteria. There was good agreement between IM residents and ID physicians/pharmacists on meropenem appropriateness. IM residents could contribute to antimicrobial stewardship efforts, like prospective audit and feedback, using standardized criteria for appropriateness.

Using a large, geographically diverse, hospital-based database in the United States (Premier PINC AI Healthcare Database), we aimed to describe the proportion and characteristics of patients receiving phenotype-desirable antimicrobial therapy (PDAT) among those hospitalized with Enterobacterales bloodstream infections.

Adult patients with an admission between January 1, 2017 and June 30, 2022 with ≥1 blood culture positive for Escherichia coli, Klebsiella oxytoca, Klebsiella pneumoniae, or Proteus mirabilis and receiving an empiric antibiotic therapy on blood culture collection (BCC) Days 0 or 1 were included. Receiving PDAT (defined as receipt of any antimicrobial categorized as “desirable” for the respective phenotype) on BCC Days 0−2 was defined as receiving early PDAT.

Among 35,880 eligible patients, the proportion of patients receiving PDAT increased (from 6.8% to 22.8%) from BCC Day 0−4. Patients who received PDAT (8,193, 22.8%) were more likely to visit large (500 + beds, 36% vs 31%), teaching (45% vs 39%), and urban (85% vs 82%) hospitals in the Northeast (22% vs 13%) compared to patients not receiving PDAT (all P <. 01). Among patients receiving PDAT, 61.4% (n = 5,033) received it early; they had a lower mean comorbidity score (3.2 vs 3.6), were less likely to have severe or extreme severity of illness (71% vs 79%), and were less likely to have a pathogen susceptible to narrow-spectrum β-lactams (31% vs 71%) compared to patients in the delayed PDAT group (all P < .01).

The proportion of patients receiving desirable therapy increased between BCC Day 0 and 4. Receipts of PDAT and early PDAT were associated with hospital, clinical, and pathogen characteristics.

To measure SARS-CoV-2 anti-nucleocapsid (anti-N) antibody seropositivity among healthcare personnel (HCP) without a history of COVID-19 and to identify HCP characteristics associated with seropositivity.

Prospective cohort study from September 22, 2020, to March 3, 2022.

A tertiary care academic medical center.

727 HCP without prior positive SARS-CoV-2 PCR testing were enrolled; 559 HCP successfully completed follow-up.

At enrollment and follow-up 1–6 months later, HCP underwent SARS-CoV-2 anti-N testing and were surveyed on demographics, employment information, vaccination status, and COVID-19 symptoms and exposures.

Of 727 HCP enrolled, 27 (3.7%) had a positive SARS-CoV-2 anti-N test at enrollment. Seropositive HCPs were more likely to have a household exposure to COVID-19 in the past 30 days (OR 7.92, 95% CI 2.44–25.73), to have had an illness thought to be COVID-19 (4.31, 1.94–9.57), or to work with COVID-19 patients more than half the time (2.09, 0.94–4.77). Among 559 HCP who followed-up, 52 (9.3%) had a positive SARS-CoV-2 anti-N antibody test result. Seropositivity at follow-up was associated with community/household exposures to COVID-19 within the past 30 days (9.50, 5.02–17.96; 2.90, 1.31–6.44), having an illness thought to be COVID-19 (8.24, 4.44–15.29), and working with COVID-19 patients more than half the time (1.50, 0.80–2.78).

Among HCP without prior positive SARS-CoV-2 testing, SARS-CoV-2 anti-N seropositivity was comparable to that of the general population and was associated with COVID-19 symptomatology and both occupational and non-occupational exposures to COVID-19.

Antimicrobial resistance (AMR) renders many bacterial infections untreatable and results in substantial morbidity and mortality worldwide. Understanding antibiotic use in clinical settings including hospitals is critical to optimize antibiotic use and prevent resistance.

Hospital antibiotic point prevalence survey (PPS).

The study was conducted in two large, teaching hospitals in Addis Ababa, Ethiopia. We performed two survey rounds in December 2021 and January 2022 through real-time chart review using the World Health Organization PPS methodology. Data were collected using a web-based database, and descriptive statistics were performed to analyze antibiotic use by various characteristics.

Among 1020 hospitalized patients, 318 (32%) were ≤14 years and 370 (36%) had surgery during the current hospitalization. A total of 662 (65%) were receiving an antibiotic on the day of survey and 346 (39%) were receiving ≥2 antibiotics. A community-acquired infection (43%) was the most common indication for an antibiotic followed by surgical prophylaxis (27%) and hospital-acquired infection (23%). Antibiotic use was highest among those ≤24 months in age and among patients in trauma, surgical, and pediatric wards. Cephalosporin (42%) and penicillin (16%) antibiotics were the most frequently prescribed classes. Only 11% of patients on antibiotics had samples collected for microbiological testing; hence, almost all antibiotic therapy was empiric.

Despite global and national efforts to improve antimicrobial stewardship, antibiotic use remains high in urban teaching hospitals in Ethiopia. Implementation of antimicrobial stewardship activities and microbiology utilization are needed to guide antimicrobial selection and curtail antibiotic overuse.

Community-acquired pneumonia (CAP) is a leading cause of hospitalizations and mortality in the US. Overuse of extended spectrum antibiotics (ESA) for CAP contributes to antimicrobial resistance. The 2019 Infectious Diseases Society of America/American Thoracic Society CAP guidelines emphasize de-escalation of ESA following negative cultures, early switch to oral (PO) antibiotics, and limited duration of therapy (DOT). This study describes clinicians’ acceptance of an infectious diseases-trained (ID) pharmacist-led stewardship recommendations in hospitalized patients with CAP.

This prospective, single-arm, cohort study included adults admitted with a diagnosis of pneumonia to six Cleveland Clinic hospitals receiving ID pharmacist-led stewardship recommendations. The ID pharmacist provided recommendations for ESA de-escalation, DOT, intravenous (IV) to PO transition, and antimicrobial discontinuation. Descriptive statistics were used to describe clinician acceptance rates.

From November 1, 2022, to January 31, 2024, the ID pharmacist made recommendations for 685 patient encounters to 327 clinicians. Of these patients, 52% received an ESA and 15% had severe CAP. There were 959 recommendations: ESA de-escalation (19%), DOT (46%), IV to PO transition (19%), antimicrobial discontinuation (13%), and other (3%). Clinicians accepted 693 recommendations (72%): IV to PO transition (148/184, 80%), ESA de-escalation (141/181 78%), antimicrobial discontinuation (94/128, 73%), DOT (286/437, 65%), and other (24/29, 83%).

Clinicians were generally receptive to ID pharmacist-led CAP recommendations with an overall acceptance rate of 72%. Prescribers were most receptive to recommendations for IV to PO conversion and least receptive to limiting DOT.

This study describes trends in COVID-19 hospitalizations and healthcare-associated (HA) COVID-19 in Canada among pediatric (age <18 years) patients during pre-Omicron and Omicron-dominant periods.

Prospective surveillance for COVID-19 infection

The Canadian Nosocomial Infection Surveillance Program is a sentinel surveillance system with 45 hospitals providing COVID-19 data on pediatric patients, including all 13 pediatric tertiary care facilities in Canada.

Pediatric patients hospitalized with laboratory-confirmed COVID-19 at a participating hospital between March 1, 2020, and December 31, 2022.

Analyzed case-level data on pediatric patients with COVID-19, including demographics, acquisition source, and outcomes.

Among 5,143 pediatric cases, the majority (81%) were reported during the Omicron-dominant period (beginning December 26, 2021). However, a lower proportion required intensive care during the Omicron wave (11% vs 14%, P < 0.05); no difference in mortality was observed. Of those patients admitted to hospital due to COVID-19 (n = 2,700), 45% had at least one pre-existing comorbidity. The majority (90%) of patients with HA-COVID-19 were reported during the Omicron period. There was no difference in mortality between patients with HA and community-associated (CA) infection, although a greater proportion of CA infections led to intensive care unit admission (6% vs 13%, P < 0.01).

Surveillance findings indicate that both HA- and CA-COVID-19 hospitalizations in Canada increased among pediatric patients following the emergence of the Omicron variant, although disease severity decreased. Pre-existing health conditions were common among pediatric patients hospitalized with COVID-19, highlighting the importance of preventing severe illness in this sub-population.

Antibiotic overuse is common across walk-in clinics, but it is unclear which stewardship metrics are most effective for audit and feedback. In this study, we assessed the validity of a metric that captures antibiotic prescribing for respiratory tract diagnoses (RTDs).

We performed a mixed-methods study to evaluate an RTD metric, which quantified the frequency at which a provider prescribed antibiotics for RTD visits after excluding visits with complicating factors.

Seven walk-in clinics across an integrated healthcare system.

We included clinic visits during 2018–2022. We also conducted 17 semi-structured interviews with 10 unique providers to assess metric acceptability.

There were 331,496 visits; 120,937 (36.5%) met RTD criteria and 44,382 (36.7%) of these received an antibiotic. Factors associated with an increased odds of antibiotic use for RTDs included patient age ≥ 65 (OR = 1.40; 95% CI 1.30–1.51), age 0–17 (1.55, 95% CI 1.50–1.60), and ≥1 comorbidity (OR = 1.22; 95% CI = 1.15–1.29). After stratifying providers by their antibiotic-prescribing frequency for RTDs, patient case-mix was similar across tertiles. However, the highest tertile of prescribers more frequently coded suppurative otitis media and more frequently prescribed antibiotics for antibiotic-nonresponsive conditions (eg, viral infections). There was no correlation between antibiotic prescribing for RTDs and the frequency of return visits (r = 0.01, P = 0.96). Interviews with providers demonstrated the acceptability of the metric as an assessment tool.

A provider-level metric that quantifies the frequency of antibiotic prescribing for all RTDs has both construct and face validity. Future studies should assess whether this type of metric is an effective feedback tool.

To describe clinical syndromes, opportunities for antimicrobial optimization, and acceptance of recommendations made by an immunocompromised antimicrobial stewardship program performing in-person prospective audit and feedback (IPPAF) on inpatient oncology services.

Retrospective cohort study.

Three inpatient oncology services including patients with solid tumor malignancies in an academic cancer center.

Hospitalized adults with oncologic malignancies receive antimicrobials for any indication.

We reviewed all patients receiving antimicrobials on inpatient oncology services who were included in IPPAF and prospectively documented clinical syndromes represented, most common recommendations, and acceptance rate. We also examined the standardized antimicrobial administration ratio (SAAR) for oncology units over the study period.

Over 34 weeks, we performed 154 interventions for 138 patients. Metastatic malignancy was common (52%) and 90-day mortality was high (43%). Diagnostic uncertainty was common (33/154, 21%), as were cases of intra-abdominal pathology (30/154, 19%), pneumonia (25/154, 16%), and urinary tract infection (12/154, 8%). The most common recommendations were changes in duration (63/154, 41%) and stopping antimicrobials for syndromes determined to be noninfectious (29/154, 19%). Acceptance of interventions was high (77% overall) and several SAARs on the primary oncology unit significantly decreased after starting IPPAF.

We identified numerous opportunities for antimicrobial optimization among solid tumor malignancy patients. Most clinical syndromes were ones also encountered frequently in non-oncology populations, but several were unique and represented opportunities for targeted education.