Personal protective equipment (PPE) is a critical need during the coronavirus disease 2019 (COVID-19) pandemic. Alternative sources of surgical masks, including 3-dimensionally (3D) printed approaches that may be reused, are urgently needed to prevent PPE shortages. Few data exist identifying decontamination strategies to inactivate viral pathogens and retain 3D-printing material integrity.

To test viral disinfection methods on 3D-printing materials.

The viricidal activity of common disinfectants (10% bleach, quaternary ammonium sanitizer, 3% hydrogen peroxide, or 70% isopropanol and exposure to heat (50°C, and 70°C) were tested on four 3D-printed materials used in the healthcare setting, including a surgical mask design developed by the Veterans’ Health Administration. Inactivation was assessed for several clinically relevant RNA and DNA pathogenic viruses, including severe acute respiratory coronavirus virus 2 (SARS-CoV-2) and human immunodeficiency virus 1 (HIV-1).

SARS-CoV-2 and all viruses tested were completely inactivated by a single application of bleach, ammonium quaternary compounds, or hydrogen peroxide. Similarly, exposure to dry heat (70°C) for 30 minutes completely inactivated all viruses tested. In contrast, 70% isopropanol reduced viral titers significantly less well following a single application. Inactivation did not interfere with material integrity of the 3D-printed materials.

Several standard decontamination approaches effectively disinfected 3D-printed materials. These approaches were effective in the inactivation SARS-CoV-2, its surrogates, and other clinically relevant viral pathogens. The decontamination of 3D-printed surgical mask materials may be useful during crisis situations in which surgical mask supplies are limited.

In this study, we aimed to capture perspectives of healthcare workers (HCWs) on coronavirus disease 2019 (COVID-19) and infection prevention and control (IPAC) measures implemented during the early phase of the COVID-19 pandemic.

A cross-sectional survey of HCWs.

HCWs from the Hospital for Sick Children, Toronto, Canada.

A self-administered survey was distributed to HCWs. We analyzed factors influencing HCW knowledge and self-reported use of personal protective equipment (PPE), concerns about contracting COVID-19 and acceptance of the recommended IPAC precautions for COVID-19.

In total, 175 HCWs completed the survey between March 6 and March 10: 35 staff physicians (20%), 24 residents or fellows (14%), 72 nurses (41%), 14 respiratory therapists (8%), 14 administration staff (8%), and 14 other employees (8%). Most of the respondents were from the emergency department (n = 58, 33%) and the intensive care unit (n = 58, 33%). Only 86 respondents (50%) identified the correct donning order; only 60 (35%) identified the correct doffing order; but the majority (n = 113, 70%) indicated the need to wash their hands immediately prior to removal of their mask and eye protection. Also, 91 (54%) respondents felt comfortable with recommendations for droplet and/or contact precautions for routine care of patients with COVID-19. HCW occupation and concerns about contracting COVID-19 outside work were associated with nonacceptance of the recommendations (P = .016 and P = .036 respectively).

As part of their pandemic response plans, healthcare institutions should have ongoing training for HCWs that focus on appropriate PPE doffing and discussions around modes of transmission of COVID-19.

To assess influenza symptoms, adherence to mask use recommendations, absenteesm and presenteeism in acute care healthcare workers (HCWs) during influenza epidemics.

The TransFLUas influenza transmission study in acute healthcare prospectively followed HCWs prospectively over 2 consecutive influenza seasons. Symptom diaries asking for respiratory symptoms and adherence with mask use recommendations were recorded on a daily basis, and study participants provided midturbinate nasal swabs for influenza testing.

In total, 152 HCWs (65.8% nurses and 13.2% physicians) were included: 89.1% of study participants reported at least 1 influenza symptom during their study season and 77.8% suffered from respiratory symptoms. Also, 28.3% of HCW missed at least 1 working day during the study period: 82.6% of these days were missed because of symptoms of influenza illness. Of all participating HCWs, 67.9% worked with symptoms of influenza infection on 8.8% of study days. On 0.3% of study days, symptomatic HCWs were shedding influenza virus while at work. Among HCWs with respiratory symptoms, 74.1% adhered to the policy to wear a mask at work on 59.1% of days with respiratory symptoms.

Respiratory disease is frequent among HCWs and imposes a significant economic burden on hospitals due to the number of working days lost. Presenteesm with respiratory illness, including influenza, is also frequent and poses a risk for patients and staff.

NCT02478905 (clinicaltrials.gov)

The hands of healthcare personnel are the most important source for transmission of healthcare-associated pathogens. The role of contaminated fomites such as portable equipment, stethoscopes, and clothing of personnel in pathogen transmission is unclear.

To study routes of transmission of cauliflower mosaic virus DNA markers from 31 source patients and from environmental surfaces in their rooms.

A 3-month observational cohort study.

A Veterans’ Affairs hospital.

After providing care for source patients, healthcare personnel were observed during interactions with subsequent patients. Putative routes of transmission were identified based on recovery of DNA markers from sites of contact with the patient or environment. To assess plausibility of fomite-mediated transmission, we assessed the frequency of transfer of methicillin-resistant Staphylococcus aureus (MRSA) from the skin of 25 colonized patients via gloved hands versus fomites.

Of 145 interactions involving contact with patients and/or the environment, 41 (28.3%) resulted in transfer of 1 or both DNA markers to the patient and/or the environment. The DNA marker applied to patients’ skin and clothing was transferred most frequently by stethoscopes, hands, and portable equipment, whereas the marker applied to environmental surfaces was transferred only by hands and clothing. The percentages of MRSA transfer from the skin of colonized patients via gloved hands, stethoscope diaphragms, and clothing were 52%, 40%, and 48%, respectively.

Fomites such as stethoscopes, clothing, and portable equipment may be underappreciated sources of pathogen transmission. Simple interventions such as decontamination of fomites between patients could reduce the risk for transmission.

To examine whether the issue and dissemination of national guidelines in the Manual of Antimicrobial Stewardship had an impact on reducing antibiotic use for acute respiratory tract infection (ARTI) and gastroenteritis.

An interrupted time-series analysis was performed using a large nationwide database from June 2016 to June 2018. Outpatients with ARTI or gastroenteritis aged ≥6 years were identified. The outcome measures were any antibiotic use and broad-spectrum antibiotic use. The season-adjusted changes in the rate of antibiotic prescriptions for 2 periods before and after the guideline issue date were examined.

There were 13,177,735 patients with ARTI and 300,565 patients with gastroenteritis during the study period. Among patients with ARTI, there was a significant downward trend in antibiotic use during the 2-year study period (−0.06% per week; 95% CI, −0.07% to −0.04%). However, there was no significant change in trends of antibiotic use between the pre-issue period and post-issue period (trend difference, −0.01% per week; 95% CI, −0.10% to 0.07%). Similarly, for patients with gastroenteritis, there was no significant change in the trends of antibiotic use between the pre-issue period and post-issue period (trend difference, −0.02% per week; 95% CI, −0.04% to 0.01%). Similar associations were observed in analyses for broad-spectrum antibiotic use.

Despite the issue of national guidelines to promote the appropriate use of antibiotics, there were no significant changes in trends of antibiotic use for outpatients with ARTI or gastroenteritis between the pre-issue and post-issue periods.

The association between Clostridioides difficile colonization and C. difficile infection (CDI) is unknown in solid-organ transplant (SOT) patients. We examined C. difficile colonization and healthcare-associated exposures as risk factors for development of CDI in SOT patients.

The retrospective study cohort included all consecutive SOT patients with at least 1 screening test between May 2017 and April 2018. CDI was defined as the presence of diarrhea (without laxatives), a positive C. difficile clinical test, and the use of C. difficile-directed antimicrobial therapy as ordered by managing clinicians. In addition to demographic variables, exposures to antimicrobials, immunosuppressants, and gastric acid suppressants were evaluated from the time of first screening test to the time of CDI, death, or final discharge.

Of the 348 SOT patients included in our study, 33 (9.5%) were colonized with toxigenic C. difficile. In total, 11 patients (3.2%) developed CDI. Only C. difficile colonization (odds ratio [OR], 13.52; 95% CI, 3.46–52.83; P = .0002), age (OR, 1.09; CI, 1.02–1.17; P = .0135), and hospital days (OR, 1.05; 95% CI, 1.02–1.08; P = .0017) were independently associated with CDI.

Although CDI was more frequent in C. difficile colonized SOT patients, the overall incidence of CDI was low in this cohort.

To evaluate a method to identify hospitals contributing to Clostridioides difficile infections (CDI) at subsequent hospitalizations.

Retrospective cohort study.

We merged 2014–2015 National Healthcare Safety Network (NHSN) inpatient CDI laboratory-identified events with hospital patient discharge data. For patients with incident community-onset CDI (CO CDI), we identified immediately preceding admissions (within 12 weeks) unrelated to CDI at different (exposure) hospitals. We calculated an exposure rate, and we selected hospitals with the highest (90th–100th percentile) rates by hospital type and compared these rates with reported standardized infection ratios (SIR) for CDI.

We successfully matched 44,691 of 58,842 NHSN CDI records (76.0%) with a hospital discharge record. Among 36,215 unique matched records, 5,234 (14.5%) had an admission not related to CDI within 12 weeks prior to an incident CO CDI event, and 1,574 of these admissions (30.1%) occurred in a different hospital. For 33 hospitals with an exposure ranking within the 90th–100th percentile, CDI SIRs for 22 (66.7%) were not significantly different; 3 (9.1%) were lower; and 8 (24.2%) were higher than the national baseline. Also, 12 (36.4%) had an SIR ≤1.0.

The identification of high-ranked exposure hospitals presents an alternative to SIR for measuring the contribution of hospitals to the CDI burden across the continuum of care. Further exploration of the potential factors leading to high exposure rank, such as antibiotic use and infection control practices, is indicated and may inform CDI prevention outreach to healthcare facilities and provider networks in California and elsewhere.

To estimate the impact of California’s antimicrobial stewardship program (ASP) mandate on methicillin-resistant Staphylococcus aureus (MRSA) and Clostridioides difficile infection (CDI) rates in acute-care hospitals.

Centers for Medicare and Medicaid Services (CMS)–certified acute-care hospitals in the United States.

2013–2017 data from the CMS Hospital Compare, Provider of Service File and Medicare Cost Reports.

Difference-in-difference model with hospital fixed effects to compare California with all other states before and after the ASP mandate. We considered were standardized infection ratios (SIRs) for MRSA and CDI as the outcomes. We analyzed the following time-variant covariates: medical school affiliation, bed count, quality accreditation, number of changes in ownership, compliance with CMS requirements, % intensive care unit beds, average length of stay, patient safety index, and 30-day readmission rate.

In 2013, California hospitals had an average MRSA SIR of 0.79 versus 0.94 in other states, and an average CDI SIR of 1.01 versus 0.77 in other states. California hospitals had increases (P < .05) of 23%, 30%, and 20% in their MRSA SIRs in 2015, 2016, and 2017, respectively. California hospitals were associated with a 20% (P < .001) decrease in the CDI SIR only in 2017.

The mandate was associated with a decrease in CDI SIR and an increase in MRSA SIR.

Although infections caused by Acinetobacter baumannii are often healthcare-acquired, difficult to treat, and associated with high mortality, epidemiologic data for this organism are limited. We describe the epidemiology, clinical characteristics, and outcomes for patients with extensively drug-resistant Acinetobacter baumannii (XDRAB).

Retrospective cohort study

Department of Veterans’ Affairs Medical Centers (VAMCs)

Patients with XDRAB cultures (defined as nonsusceptible to at least 1 agent in all but 2 or fewer classes) at VAMCs between 2012 and 2018.

Microbiology and clinical data was extracted from national VA datasets. We used descriptive statistics to summarize patient characteristics and outcomes and bivariate analyses to compare outcomes by culture source.

Among 11,546 patients with 15,364 A. baumannii cultures, 408 (3.5%) patients had 667 (4.3%) XDRAB cultures. Patients with XDRAB were older (mean age, 68 years; SD, 12.2) with median Charlson index 3 (interquartile range, 1–5). Respiratory specimens (n = 244, 36.6%) and urine samples (n = 187, 28%) were the most frequent sources; the greatest proportion of patients were from the South (n = 162, 39.7%). Most patients had had antibiotic exposures (n = 362, 88.7%) and hospital or long-term care admissions (n = 331, 81%) in the prior 90 days. Polymyxins, tigecycline, and minocycline demonstrated the highest susceptibility. Also, 30-day mortality (n = 96, 23.5%) and 1-year mortality (n = 199, 48.8%) were high, with significantly higher mortality in patients with blood cultures.

The proportion of Acinetobacter baumannii in the VA that was XDR was low, but treatment options are extremely limited and clinical outcomes were poor. Prevention of healthcare-associated XDRAB infection should remain a priority, and novel antibiotics for XDRAB treatment are urgently needed.

Antibiotics are overly prescribed in nursing homes. Recent antibiotic stewardship efforts attempt to reduce inappropriate use. Our objective was to describe antibiotic use from 2012 to 2016 among nursing-home residents with various health conditions.

Retrospective, repeated cross-sectional analysis.

All long-term residents in a random 10% sample of national nursing homes: 2,092,809 assessments from 319,615 nursing-home residents in 1,562 nursing homes.

We calculated a 1-day antibiotic prevalence using all annual and quarterly clinical assessments in the Minimum Data Set (MDS) from April 2012 through December 2016. We calculated prevalence of antibiotic use overall and within conditions of interest: Alzheimer’s disease and related dementias (ADRD), advanced cognitive impairment (ACI), and infections likely to be treated with antibiotics. We applied logistic regressions with nursing-home cluster, robust standard errors to assess changes in conditions and antibiotic use 2012–2016.

Overall, antibiotic use did not change (2012 vs 2016, adjusted odds ratio [AOR], 1.00; 95% CI, 0.97–1.03). Antibiotic use was higher in 2016 versus 2012 among assessments with any infection (AOR, 1.10; 95% CI, 1.04–1.16), urinary tract infection (AOR, 1.18; 95% CI, 1.12–1.25), and no infection (AOR, 1.13; 95% CI, 1.09–1.17). Results were similar by cognitive status.

The increased proportion of assessments recording antibiotics but no infection may not be clinically appropriate. Higher antibiotic use among infected residents with advanced cognitive impairment is also concerning. Further efforts to understand mechanisms driving these trends and to promote antibiotic stewardship in nursing homes are warranted.

Antibiotic allergy labels are common and are frequently inaccurate. Previous studies among adults demonstrate that β-lactam allergy labels may lead to adverse outcomes, including prescription of broader-spectrum antibiotics, increased costs, and increased lengths of stay, among others. However, data among pediatric patients are lacking, especially in the United States. In this study, we sought to determine the impact of β-lactam allergy labels in hospitalized children with regards to clinical and economic outcomes.

This retrospective cohort study included pediatric patients 30 days to 17 years old, hospitalized at Intermountain Healthcare facilities from 2007 to 2017, who received ≥1 dose of an antibiotic during their admission. Patients with β-lactam allergies were matched to nonallergic patients based on age, sex, clinical service line, admission date, academic children’s hospital or other hospital admission, and the presence of chronic, comorbid conditions. Outcomes included receipt of broader-spectrum antibiotics, clinical outcomes including length of stay and readmission, and antibiotic and hospitalization costs.

In total, 38,906 patients were identified. The prevalence of antibiotic allergy increased from 0.9% among those < 1 year peaked at 10.6% by age 17. Patients with β-lactam allergy received broader-spectrum antibiotics and experienced higher antibiotic costs than nonallergic controls. However, there were no differences in the length of stay, readmission rates, or total number of days of antibiotics between allergic and nonallergic patients.

Hospitalized pediatric patients with β-lactam allergy labels receive broader-spectrum antibiotics and experience increased antibiotic costs. This represents an important opportunity for allergy delabeling and antibiotic stewardship.

To determine whether combinations of diagnosis and procedures codes can improve the detection of prosthetic hip and knee joint infections from administrative databases.

We performed a validation study of all readmissions from January 1, 2010, until December 31, 2016, following primary arthroplasty comparing the diagnosis and procedure codes obtained from an administrative database based upon the International Classification of Disease, Tenth Revision (ICD-10) to the reference standard of chart review.

Four tertiary-care hospitals in Toronto, Canada, from 2010 to 2016.

Individuals who had a primary arthroplasty were identified using procedure codes.

Chart review of readmissions identified the presence of a prosthetic joint infection and, if present, the surgical procedure performed.

Overall, 27,802 primary arthroplasties were performed. Among 8,844 readmissions over a median follow-up of 669 days (interquartile range, 256–1,249 days), a PJI was responsible for or present in 586 of 8,844 (6.6%). Diagnosis codes alone exhibited a sensitivity of 0.88 (95% CI, 0.85–0.92) and positive predictive value (PPV) of 0.78 (95% CI, 0.74–0.82) for detecting a PJI. Combining a PJI diagnosis code with procedure codes for an arthroplasty and the insertion of a peripherally inserted central catheter improved detection: sensitivity was 0.92 (95% CI, 0.88–0.94) and PPV was 0.78 (95% CI, 0.74–0.82). However, procedure codes were unable to identify the specific surgical approach to PJI treatment.

Compared to PJI diagnosis codes, combinations of diagnosis and procedure codes improve the detection of a PJI in administrative databases.