Background: Febrile neutropenia (FN) is the most common complication of chemotherapy-induced neutropenia that affects over 80% of patients with hematologic malignancies. National guidance and randomized controlled trial data demonstrate empiric antimicrobial therapy (EAT) can be discontinued after 72 hours of apyrexia and clinical recovery regardless of absolute neutrophil count (ANC). A 2019 internal study identified opportunity for improvement for targeted de-escalation. We aimed to reevaluate duration of EAT in patients with FN without a documented source of infection. Methods: A pharmacovigilance platform identified 110 patients from January to September 2023 without identified source of infection. Data collection was performed via manual chart review. Historic patient data from our 2019 cohort (n=50) was available in our research repository. The primary outcome was the duration of EAT in patients with at least 72 hours of apyrexia and clinical recovery, defined as normalization of vital signs. Secondary outcomes included adverse events associated with EAT, and initiation of intravenous vancomycin. Results: Baseline characteristics for 2023 were similar to historic, median age was 67.5 years, 56% were male, and median ANC at fever onset was 150 cells/μL. EAT was continued in 29 patients (58%) despite defervescence and stabilization versus 35 (70%) in 2019 (figure 1). Average duration (LOT) of EAT beyond clinical stabilization was 6 versus 7 days. Adverse effects due to EAT occurred in 13 patients in 2023 (26%) versus 4 (8%); of which, C. difficile infection (CDI) was the greatest contributor. Vancomycin was initiated in 31 patients (62%), 22 having no identifiable indication. Conclusions: Rates of EAT de-escalation for neutropenic patients after 72 hours of apyrexia and clinical stability improved by 12% as compared to 2019. Mean days of overall EAT was 3 days less in 2023. With a notable increase in CDI rates in 2023, dedicated time for antimicrobial stewardship review, clinician education and guideline driven alerts for review will be explored to help further improve practice.

Inaccurate penicillin allergy labeling may deter healthcare providers from initiating appropriate therapy and contribute to antibiotic resistance. In a rural urgent care setting, the current practice of penicillin allergy labeling was evaluated using the PEN-FAST tool. The results confirm opportunity to further evaluate and improve current practice for allergy assessment.

Objective: Mycobacterium tuberculosis (MTB) is a contagious airborne disease that is spread from person to person via particles in the air which are expelled when speaking or coughing1. This retrospective observational study aims to assess the nosocomial transmission of pulmonary MTB among inpatient roommates in a high-risk oncological population over a 14-year period. With limited studies on the transmissibility of MTB in such environments, the investigation focuses on evaluating the risk of nosocomial transmission and implementation of appropriate infection control measures. Design: A retrospective analysis from 2010 – April 2023 was conducted in an acute care, 500-bed oncological center. Following exposure workups performed by the Department of Infection Prevention and Control, 17 of 57 identified patients with active pulmonary MTB had inpatient stays with roommates. Source infectivity showed 7 AFB smear positive results, 4 MTB PCR positive results, and 14 MTB culture positive results. Some index patients had a combination of AFB, PCR and/or culture positivity. A high-risk exposure is defined as any patient who shared a room with an index patient for >4 cumulative hours during the infectious period. Infectious period was determined for each index patient based on the onset of symptoms and laboratory results. Workups identified 33 exposed roommates who were notified and advised to undergo testing, employing QuantifERON (QFT-GIT) serum test or Tuberculin skin (TST) PPD test at least 8 weeks following their last day of exposure. The overlap between inpatient roommates and index patients ranged from 1 to 4 days, averaging 1.5 days. Results: Of the 33 high-risk roommates, 14 (42%) patients were unable to provide follow-up testing for various reasons including: patient expiration prior to testing, patient transfer to hospice, and being lost to follow up. Nineteen (58%) patients completed post-exposure testing. 12 patients underwent PPD testing (63%) and 7 patients underwent QuantifERON testing (37%). Zero (0%) were found to have a positive QuantifERON or PPD following their exposure. 15.8% (N=3) of exposed patients had hematologic malignancies, and 84.2% (N=16) of exposed patients had solid tumor malignancies. Conclusion: The risk of active pulmonary MTB transmission in an oncological, inpatient setting was determined to be low. The absence of positive conversions among roommates of confirmed MTB patients underscores the effectiveness of infection control measures, emphasizing the importance of isolating confirmed or suspected cases promptly. Ongoing efforts should continue to focus on these preventive measures to mitigate the risk of MTB transmission in similar high-risk settings.

References: 1. How TB Spreads. CDC, 2023. https://www.cdc.gov/tb/topic/basics/howtbspreads.htm

Background: The role of the infection preventionist (IP) is complex and encompasses a range of responsibilities requiring extensive knowledge in infection control practices, data analysis, surveillance, performance improvement and collaboration with multidisciplinary teams. Infection prevention certification (CIC) by the certification Board of Infection Control (CBIC) is a standardized marker of knowledge and competencies required for practice in the field. In a 2020 survey of IPs, less than half were certified or planned to become certified. Of those that do take the certification exam, less than three quarters pass on their initial exam attempt. Methods: From 2017 to 2023, fifty-two new IPs were enrolled in a competency-based training program which combined didactic and applied learning on core IP job functions, and a structured mentoring program. The initial didactic phase consisted of evidence-based learning modules with validation of competency through post-training testing and practical demonstration. Education was provided by an advanced practice IP via remote webinars, which included discussion of questions, skills coaching, and review of post-tests. Novice IPs were partnered with at least two preceptors: one advanced practice lead preceptor guided the novice IPs through assigned education modules and oversaw program management and training benchmarks. A second, near-peer preceptor or mentor collaborated with the novice IP in the facility setting. Initial training focused on facility operations, surveillance, rounding and other facility specific activities. Facility mentors were responsible for combining education module topics with practical application of skills. Mentors guided novice IPs through National Healthcare Surveillance network (NHSN) surveillance training and validated surveillance and infection coding until the novice IP had an interrater reliability validation assessing surveillance competency. After the initial training phase, the novice IPs began preparation for certification. This phase included additional training modules aligned with the CBIC certification content outline and practice exams. Results: All 52 novice IPs completed the training program and attempted the CIC examination. The initial pass rate for the certification exam among IPs in the supervised training and mentorship program was 98.1% (n=51). This is 33% higher than the initial pass rate published by CBIC, which was 73.9% (Figure 1). Conclusions: Organizing evidence-based guidelines into topic-specific modules builds a foundation of infection prevention and control knowledge, which is enhanced through remote instruction and direct application of skills under a preceptor’s supervision. This method allows IPs to be introduced to concepts covered in the board certification exam upon hire and support certification with improved outcome

Background: Hospitals are increasingly consolidating into networks and integrating infection prevention (IP) into system infection prevention programs (SIPP). Very little has been published about these programs. This survey sheds light on the current state of SIPPs. Methods: We used the survey generator Alchemer.com for setting up the questionnaire, and tested a beta version among peers. The final version was sent out to SHEA Research Network participants in August 2023. Raw data was compiled and analyzed. Results: Forty institutions responded (40/104, 38%), of which 25 (63%) had SIPPs. These SIPPS reported health systems with a median of 4.5 acute care hospitals (range, 1-33); 16 SIPPS reported a median of 2 critical access hospitals (range, 1-8); 4 SIPPs reported 1-3 LTACHs, and 6 SIPPS reported a median of 1.5 nursing homes. All except 3 (88%) contained an academic center; 48% (11/23) of the U.S. based programs operate in multiple states. Four programs have been in place >20 years, four < 2 years, and the remainder a median of 8 years (range, 2-18). Physician directors also have clinical (20/25, 80%), teaching (19/25, 76%), research (15/25, 60%), antimicrobial stewardship (8/25, 32%), quality (8/25, 32%), and/or patient safety (5/25, 20%) roles. Seventeen (68%) report having a written job description. Nineteen (76%) report having an infection preventionist in a system IP director role; only 7/25 (28%) have a dedicated system IP team that operates independent of individual hospitals. Sixteen (64%) report administrative support, 10/25 (40%) have a data manager/analyst, and 4/25 (16%) include IT expert or programmer support. 15/25 (60%) report having done a formal system-wide IP needs assessment. While 16/25 (64%) have some automation in HAI surveillance (predominantly using Bugsy [Epic] or Theradoc [Premier]), while only 5/25 (20%) run fully automated surveillance. 10/25 (40%) have implemented centralized surveillance. 12/25 (48%) have “system IP policies” that are hierarchically above individual site policies. The biggest challenges appear to be gaps in 1) clear governing structure, 2) communication, 3) consistent staffing, 4) data management support, and 5) dedicated, empowered IP expert FTEs. Conclusions: To our knowledge, this is the first U.S. survey to explore present-day system infection prevention. In this sample of hospital networks, we found heterogeneity in the structure, staffing and resources for system IP with significant opportunities for improvement. In this era of healthcare consolidation, our findings highlight the urgent need to more clearly delineate and support system IP needs in order to enhance their functionality.

Deploying novel COVID-19 therapies proved challenging amid rapidly evolving data, drug shortages, and conflicting guidelines. We established a remdesivir formulary restriction remdesivir to promote its evidence-based use. This intervention led to changes in remdesivir utilization patterns and cost savings. Formulary restrictions can play an important role in pandemic preparedness and response.

Background: COVID19 remains deadly to Americans over 75 years old despite vaccination and additional infection control practices in long term care (LTC). The evolution of more transmissible COVID19 variants and continued viral aerosols result in persistent COVID19 outbreaks in LTC during high community levels of COVID19. Despite the end of pandemic Federal support and the continued vulnerability of elderly to the virus, LTC facilities remain dedicated to protecting this vulnerable population. The study hypothesized that utilization of continuous, facility-wide, advanced photocatalysis (AP) disinfection technology will reduce microbial burden in air and on surfaces, demonstrating a decrease in infectious aerosols and subsequent COVID19 cases among residents and workers. Methods: A prospective facility controlled experimental study was performed in skilled nursing facilities in Pennsylvania and New Jersey from January 2023 to April 2023 to surveil aerobic bacterial and fungal colony forming units (CFUs) in air, and Methicillin-resistant Staphylococcus aureus (MRSA) and fungal CFUs on surfaces and floors prior to and post AP technology installation. Impacts on resident COVID19 cases were recorded and compared to the same extended observation period (February-July 2023) one year prior (2022) with similar year over year community COVID19 rates. In addition, two matched control centers in regional proximity to the intervention facility were also prospectively studied. A one-way analysis of variance (ANOVA) was used to analyze mean microbial burdens after each post activation period (significance p <.05). Results: From baseline to final testing, the intervention facility surface testing showed a 93% reduction in mean aerobic bacterial CFUs (p=.002); 96% reduction in mean fungal CFUs (p<.001); 97% reduction in mean MRSA CFUs (p<.001). Floor testing also showed reductions in mean CFUs for aerobic bacteria by 92% (p<.001); 96% for fungi (p<.001); 99% for MRSA (p<.001). Air testing showed reductions in mean CFUs for aerobic bacteria by 87% (p=.005); 36% for fungal (p=.005). The intervention facility observed a 94% reduction in resident COVID19 cases compared to the matched control facilities that increased 46% during the 2023 time period (Figure 1). Conclusion: This study is on the pioneering edge of demonstrating that continuous and persistent disinfection technology reduces contaminant reservoirs on surfaces, floors, and air and clearly decreases infectious aerosols and improves resident outcomes by dramatically reducing COVID19 transmission in LTC facilities.

In this survey of infection prevention and control (IPC) professionals, we gauged knowledge, attitudes and institutional practices related to environmental sustainability and IPC. Overall, IPC professionals have not yet universally adopted measures to promote environmental sustainability. More research is needed around environmentally sustainable efforts that preserve patient safety in IPC.

In a cross-sectional study of 20 Massachusetts long-term care (LTC) facilities, 19% (n = 449) of residents received antibiotics, with approximately one-third having a documented penicillin allergy. This documented allergy decreased the likelihood of prescribing beta-lactam antibiotics for infections. Improved penicillin allergy assessments and delabeling could optimize antibiotic prescribing in LTC settings.

Background: We know relatively little about how healthcare personnel (HCP) in long-term care facilities (LTCFs) integrate hand hygiene (HH) and personal protective equipment (PPE; e.g., gloves) use into their care processes. To address this gap, we are examining HH and PPE adherence at critical and contaminating moments in LTCFs. Methods: We conducted ethnographic observations of HCP’s processes of care in 2 LTCFs in Iowa to examine HH and PPE adherence during contaminating tasks in resident care sequences. We captured care observations and additional data on topics related to our study focus (e.g., unit/room layouts, PPE storage, facility policies/procedures) in field notes. We transcribed and imported fieldnotes into MAXQDA qualitative data management software and analyzed the data using a combined deductive-inductive coding approach. Results: Between 1/2023-7/2023, we observed 60 (30 per facility) care episodes. Most observations included toileting activities and perineal care during which HCP would be expected to use gloves and/or do HH. Most HCP appropriately donned/doffed gloves and practiced HH at key moments (e.g., before clean/aseptic procedures, after perineal care), but were less compliant before/after touching residents’ clothing or bare skin during these activities. In addition, some held soiled items next to their scrubs between tasks, which could contaminate their clothing and arms and could facilitate transmission of pathogens to other residents. Moreover, HCP’s interactions with floors emerged inductively as a topic of interest during our observations and preliminary analyses. We observed HCP interact with the floor during these activities in ways that could increase risk of pathogen transmission. HCP frequently dropped soiled towels or wipes used in perineal care onto the floor during tasks for later pick up. HCP also moved or placed trash bags containing soiled or contaminated items on the floor. HCP routinely knelt on, sat on, or touched their hands on the same floor when talking with residents, helping residents change clothes or diapers, changing bedding, or adjusting wheelchair footpads. In one case, the HCP picked up clean towels that fell to the floor near soiled towels and then used the “clean towels” in resident perineal care. Conclusion: Despite practicing HH and appropriate PPE use, HCP in LTCFs may increase the risk of pathogen transmission unintentionally through their interactions with soiled items and the environment, including floors. Given the nature of resident care in LTCFs, HCP in LTCF may be more likely than HCP in acute care settings to interact with contaminated floors.

After an educational campaign about reasonable use of cefazolin for surgical prophylaxis, optimal preoperative antibiotic regimen utilization increased from 52% to 67% (P = 0.011). Education to physicians on penicillin allergies may contribute to meaningful increases in use of optimal antibiotics while reducing readmissions and acute care length of stay.

Background: Infections due to antibiotic resistant bacteria are increasing worldwide and while, the epidemiology of these pathogens is well described in adults, pediatric specific data are lacking. We sought to gain an understanding of the risk factors for multi-drug resistant Gram-negative (MDRGN) infections in our pediatric population. Methods: We performed a retrospective review of pediatric patients seen at a pediatric hospital system in 2022 who had a culture-positive MDRGN, which was defined as a gram-negative bacteria resistant or intermediate to at least 1 antibiotic in ≥ 3 antibiotic groups. Repeat positive cultures for the same MDRGN were considered a single infection episode if occurring within a 14-day period. Demographic, clinical, and microbiologic data was obtained from the electronic medical record. Fisher’s exact was used for analysis. Results: One hundred and seventy-nine children had 237 infection episodes during the study period. Eighty-one patients (45%) were male and the median age was 5.3 years. The most prevalent MDRGNs included: Escherichia coli (154, 65%), Klebsiella spp (52, 22%), and Enterobacter spp (16, 7%). Escherichia coli was significantly more likely than other pathogens to be isolated from the urine (P = 0.008). Compared to multi-drug resistant E. coli, patients with a non-E. coli MDRGN were significantly more likely to have an underlying medical condition, recent hospitalization and antibiotic use (P≤0.001 for each, Table 1). A carbapenem was administered in 32% (75/237) of infection episodes. There were only 6 carbapenem resistant organisms. Conclusions: In our study, E. coli was the most frequent MDRGN. Most patients with a non-E. coli MDRGN infection episode had an underlying medical condition, recent hospitalization and antibiotic use. Carbapenem resistance was infrequent, though surveillance studies are needed to identify changing antibiotic resistance patterns and to direct prevention measures.

Background: In August 2023, an infection preventionist at an acute care hospital in Alabama recognized an increase in cases of Stenotrophomonas maltophilia, which is an emerging pathogen in clinical settings worldwide. It was not until the facility identified the pathogen in their water system in October that it was reported to ADPH as an outbreak. The outbreak investigation was brief due to the hospital’s rapid containment response and adherence to its established water management program (WMP). As a result of inappropriate antibiotic use in hospitals, pan-resistant strains have been increasing at an alarming rate. The pathogen can employ water used in hospital settings to cause a variety of nosocomial infections, including those found in the blood, respiratory tract, urinary tract, and on the skin. Hospitalized patients, especially those with immunocompromising conditions or implanted medical devices, are at increased risk of significant morbidity and mortality. The aim of this study was to better understand the clinical and demographic characteristics of the 13 case-patients identified during this investigation. Methods: A retrospective case series was conducted by reviewing medical records for case-patients with culture-confirmed S. maltophilia admitted between July and November. The CDC Healthcare-Associated Infection Outbreak Investigation Abstraction Form was used to systematically collect details about each case-patient’s hospitalization and course of illness. A Gantt chart was developed in Microsoft Excel to illustrate key events during their hospitalization. Results: Of the 13 case-patients, 69% were male and the median age was 69 years (range: 30 to 77). All S. maltophilia infections were hospital-acquired (>3 days after admission) with 92% being respiratory and 46% resistant to more than one class of antibiotics. All case-patients were admitted to the ICU and had known risk factors associated with developing S. maltophilia infection, including intubation (100%) and receiving antibiotic therapy prior to infection (77%). Other major risk factors included invasive surgery (77%), co-infections (77%), chronic respiratory disease (62%), hypertension (54%), and renal failure (31%). All were severely immunocompromised. Forty-six percent of the case-patients died from complications associated with their illness. Conclusion: This is the first S. maltophilia outbreak reported in Alabama. The findings of this case series underscored the importance of employing strict infection prevention measures to reduce poor health outcomes and how strong antibiotic stewardship programs are needed to limit transmission among vulnerable patient populations in these settings. It is recommended that hospitals conduct routine environmental sampling and have a WMP that is effective in limiting S. maltophilia.

Background: The Colorado Department of Public Health and Environment (CDPHE) detected an increase in Klebsiella pneumoniae carbapenemase-producing carbapenem-resistant Enterobacterales (KPC-CRE) infections in October 2022. We investigated patient epidemiological links and isolate relatedness to characterize interfacility transmission of KPC-CRE in the Denver metro area and inform regional prevention strategies. Methods: We defined a case as polymerase chain reaction detection of KPC from clinical or screening specimens collected during January 2022 – January 2023. Cases were identified through statewide CRE surveillance and carbapenemase testing at the CDPHE laboratory and counted once within a 30-day period. Medical records were reviewed to identify healthcare facility admissions and patient facility overlap in the 12 months prior to sample collection. Whole genome sequencing (WGS) was performed for 34 patients with available KPC-CRE isolates using short- and long-read sequencing techniques. We performed multi-locus sequence typing, generated genome phylogenetic trees, and compared plasmid contig sequences to identify relatedness between KPC-CRE isolates. Clusters were defined as ≥2 genetically related isolates of the same organism or carbapenemase plasmid, from different patients. Results: We identified 48 cases (34 clinical and 14 screening) among 39 patients (figure). Patients had a mean age of 52 years (range 16-86) and median of three healthcare facility admissions (range 1-14). Twenty-eight patients (72%) were male. We identified 16 (41%) patients with epidemiological links to one acute care hospital (ACH), 11 (28.2%) patients to one long-term acute care hospital (LTACH), and four (10.2%) patients to each of two ventilator-capable skilled nursing facilities (vSNF). Five distinct clusters of KPC-CRE were identified by WGS among 23 patients (E. hormaechei, two distinct E. cloacae clusters, K. pneumoniae, and K. oxytoca) with linkages to ten healthcare facilities, including two vSNFs, two LTACHs, and six ACHs. Three distinct KPC genes were identified among the clusters: KPC-2, KPC-3, and KPC-4. Genomes assembled from long reads identified identical or similar KPC-gene-containing plasmids across different species or sequence types, suggesting horizontal gene transfer of KPC. Conclusions: Multiple KPC-CRE strains co-circulated and were associated with patient movement between acute and post-acute care settings. WGS allowed us to identify multi-facility clusters. Time and location of carbapenemase acquisition were challenging to determine for genetically related isolates when epidemiologic links could not be determined from medical records. This could be due to undetected cases. We notified healthcare facilities of their shared transmission risk and advocated for improved attention to infection control, carbapenemase screening, and communication upon patient transfer.

Background: Stenotrophomonas maltophilia (SM) is a non-fermenting, Gram-negative bacillus. Its intrinsic resistance to many beta-lactams makes for challenging treatment decisions. A preprint of the latest Infectious Diseases Society of America (IDSA) guidance on managing SM infections was published in December 2022 providing a recommendation for combination therapy including trimethoprim/sulfamethoxazole (TMP/SMX) and a second agent. An evaluation of the impact on SM treatment practices following this guidance was conducted at our institution. Methods: A list of 130 patients with non-urine SM cultures from December 2021-August 2023 was generated using a pharmacovigilance platform. Patients were excluded if on comfort measures or discharged to hospice prior to therapy completion, no directed antibiotics were given, or any history of prior SM infection. Twenty-five patients were randomly selected from the pre- and post-guidance periods (before and one month after December 1, 2022) for a total of 50 patients. Data was collected via manual chart review. The primary endpoint was frequency of combination antibiotic therapy in each time period. Secondary endpoints included treatment success (defined as resolution of infection symptoms and lack of infection recurrence), in-hospital mortality, 30-day mortality, and 30-day infection recurrence. Results: Overall, baseline characteristics were similar between groups, the median age was 65 years, 64% of patients were male, 20% were immunocompromised based on prespecified criteria, the median Charlson comorbidity index was 5 (21% estimated 10-Year survival), and 76% of SM cultures were pulmonary isolates. Displayed in figure 1, combination therapy was given in 6 of 25 cases (24%) in the post-guidance group and zero patients in the pre-guidance group. Secondary endpoints of treatment success and all-cause mortality were similar between groups. Duration of therapy was similar between combination and non-combination therapy regimens (median 9 vs 10 days). Among patients who received combination therapy, all had ID consultation, 4 (66.7%) were admitted to the ICU, and 2 (33.3%) had treatment success. Conclusions: Patients treated for SM infection at our institution in the post-IDSA guidance period were more likely to receive combination therapy. A higher rate of treatment success was not observed in the post-IDSA guidance arm for SM infections. Limitations of this study include its small sample size and retrospective design, leading to inability to distinguish colonization from true infection. Additional studies are needed to evaluate the impact of combination antibiotic therapy on outcomes.

We investigated the impact of rapid diagnostic testing with real-time stewardship intervention on patients with Streptococcal bacteremia. Compared to pre-intervention, patients in the post-intervention group received more rapid antibiotic de-escalation (42 vs 88 h), and were more commonly de-escalated to narrow-spectrum (86% vs 52%) and oral antibiotics (30% vs 14%).