Antimicrobial stewardship program (ASP) interventions, such as prospective audit and feedback (PAF), have been shown to reduce antimicrobial use and improve patient outcomes. However, the optimal approach to PAF is unknown.

We examined the impact of a high–intensity interdisciplinary rounds–based PAF compared to low–intensity PAF on antimicrobial use on internal medicine wards in a 400–bed community hospital.

Prior to the intervention, ASP pharmacists performed low–intensity PAF with a focus on targeted antibiotics. Recommendations were made directly to the internist for each patient. High–intensity, rounds–based PAF was then introduced sequentially to 5 internal medicine wards. This PAF format included twice–weekly interdisciplinary rounds, with a review of all internal medicine patients receiving any antimicrobial agent. Antibiotic use and clinical outcomes were measured before and after the transition to high–intensity PAF. An interrupted time–series analysis was performed adjusting for seasonal and secular trends.

With the transition from low–intensity to high–intensity PAF, a reduction in overall usage was seen from 483 defined daily doses (DDD)/1,000 patient days (PD) during the low–intensity phase to 442 DDD/1,000 PD in the high–intensity phase (difference, −42; 95% confidence interval [CI], −74 to −9). The reduction in usage was more pronounced in the adjusted analysis, in the latter half of the high intensity period, and for targeted agents. There were no differences seen in clinical outcomes in the adjusted analysis.

High–intensity PAF was associated with a reduction in antibiotic use compared to a low–intensity approach without any adverse impact on patient outcomes. A decision to implement high–intensity PAF approach should be weighed against the increased workload required.

To determine the impact of a passive, prescriber-directed, electronic best-practice advisory coupled with prescriber education on the rate of antibiotic prescribing for acute, uncomplicated bronchitis in ambulatory adults across a large health system.

This study was a quasi-experiment examining antibiotic prescribing for ambulatory adults with acute bronchitis from January 1, 2016 through December 31, 2018. The intervention was implemented in December 2016 for emergency departments and urgent care clinics followed by ambulatory clinics in September 2017.

Outpatient settings across a health system, including 15 emergency departments, >30 urgent care clinics, and >150 ambulatory clinics.

All adults with a primary diagnosis of acute bronchitis who were seen and discharged from a study site were included.

A passive, prescriber-directed, best-practice advisory for treatment of acute bronchitis in the electronic health record and an optional, online education module regarding acute bronchitis.

The study included 81,975 ambulatory adults with a primary diagnosis of acute bronchitis during the preintervention period (19.8% >65 years of age; 61.9% female) and 89,571 ambulatory adults during the postintervention period (16.5% >65 years of age; 61.1% female). Antibiotic prescribing rates decreased from 60.8% (49,877 of 81,975 patients) preintervention to 51.4% (46,018 of 89,571 patients) postintervention (absolute difference, 9.4%; P < .001). The largest reduction occurred in the emergency departments.

An electronic best practice advisory combined with prescriber education was associated with a statistically significant reduction in antibiotic prescribing for adults with acute bronchitis. Future studies should incorporate patient education and address prescriber-reported barriers to appropriate antibiotic prescribing.

To characterize the magnitude of virus contamination on personal protective equipment (PPE), skin, and clothing of healthcare workers (HCWs) who cared for patients having acute viral infections.

Prospective observational study.

Acute-care academic hospital.

A total of 59 HCWs agreed to have their PPE, clothing, and/or skin swabbed for virus measurement.

The PPE worn by HCW participants, including glove, face mask, gown, and personal stethoscope, were swabbed with Copan swabs. After PPE doffing, bodies and clothing of HCWs were sampled with Copan swabs: hand, face, and scrubs. Preamplification and quantitative polymerase chain reaction (qPCR) methods were used to quantify viral RNA copies in the swab samples.

Overall, 31% of glove samples, 21% of gown samples, and 12% of face mask samples were positive for virus. Among the body and clothing sites, 21% of bare hand samples, 11% of scrub samples, and 7% of face samples were positive for virus. Virus concentrations on PPE were not statistically significantly different than concentrations on skin and clothing under PPE. Virus concentrations on the personal stethoscopes and on the gowns were positively correlated with the number of torso contacts (P < .05). Virus concentrations on face masks were positively correlated with the number of face mask contacts and patient contacts (P < .05).

Healthcare workers are routinely contaminated with respiratory viruses after patient care, indicating the need to ensure that HCWs complete hand hygiene and use other PPE to prevent dissemination of virus to other areas of the hospital. Modifying self-contact behaviors may decrease the presence of virus on HCWs.

To describe barriers and facilitators to the adoption of recommended infection prevention and control (IPC) practices among healthcare workers (HCWs).

A qualitative research design was used. Individual semistructured interviews with HCWs and observations of clinical practices were conducted from February to May 2018 in 8 care units of 2 large tertiary-care hospitals in Montreal (Québec, Canada).

We interviewed 13 managers, 4 nurses, 2 physicians, 3 housekeepers, and 2 medical laboratory technologists. We conducted 7 observations by following IPC nurses (n = 3), nurses (n = 2), or patient attendants (n = 2) in their work routines. Barriers to IPC adoption were related to the context of care, workplace environment issues, and communication issues. The main facilitator of the IPC adoption by HCWs was the “development of an IPC culture or safety culture.” The “IPC culture” relied upon leadership support by managers committed to IPC, shared belief in the importance of IPC measures to limit healthcare-associated infections (HAIs), collaboration and good communication among staff, as well as proactivity and ownership of IPC measures (ie, development of local solutions to reduce HAIs and “working together” toward common goals).

Adoption of recommended IPC measures by HCWs is strongly influenced by the “IPC culture.” The IPC culture was not uniform within hospital and differences in IPC culture were identified between care units.

To reduce surgical site infection (SSI) incidence in plastic surgery and hand surgery.

Uncontrolled before-and-after study.

Department of plastic surgery and hand surgery of a tertiary-care teaching hospital.

Patients undergoing surgery between January 2016 and April 2018.

A comprehensive unit-based safety program (CUSP) consisting of a bundle of evidence-based SSI prevention strategies and a change in safety culture was fully implemented after a 14-month baseline surveillance and implementation period. SSI surveillance was performed over an intervention period of another 14 months, and differences in SSI rates between the 2 periods were calculated. Adherence with bundle components and risk factors for SSI were further evaluated in a case-cohort analysis.

Of 3,321 patients, 63 (1.9%) developed an SSI, 38 of 1,722 (2.2%) in the baseline group and 25 of 1,599 (1.6%) in the intervention group (P = .20). The CUSP was associated with an adjusted relative SSI risk reduction of 41% (95% confidence interval [CI], 0.4%–65%; P = .048) in multivariable analysis, whereas the need for revision surgery increased SSI risk (odds ratio [OR], 2.63; 95% CI, 1.31–5.30; P = .007). During the intervention period, the proportion of checklists completed was 62.4%, and no difference in adherence with bundle components between patients with and without SSI was observed.

This CUSP helped reduce SSI in a surgical specialty with a low baseline SSI incidence, even though adherence with checklist completion was moderate and the main modifiable risk factors remained unchanged over time. Programs that include safety culture change may more effectively promote SSI reduction than prevention bundles alone.

Surgical site infections (SSIs) are common surgical complications that lead to increased costs. Depending on payer type, however, they do not necessarily translate into deficits for every hospital.

We investigated how surgical site infections (SSIs) influence the contribution margin in 2 reimbursement systems based on diagnosis-related groups (DRGs).

This preplanned observational health cost analysis was nested within a Swiss multicenter randomized controlled trial on the timing of preoperative antibiotic prophylaxis in general surgery between February 2013 and August 2015. A simulation of cost and income in the National Health Service (NHS) England reimbursement system was conducted.

Of 5,175 patients initially enrolled, 4,556 had complete cost and income data as well as SSI status available for analysis. SSI occurred in 228 of 4,556 of patients (5%). Patients with SSIs were older, more often male, had higher BMIs, compulsory insurance, longer operations, and more frequent ICU admissions. SSIs led to higher hospital cost and income. The median contribution margin was negative in cases of SSI. In SSI cases, median contribution margin was Swiss francs (CHF) −2045 (IQR, −12,800 to 4,848) versus CHF 895 (IQR, −2,190 to 4,158) in non-SSI cases. Higher ASA class and private insurance were associated with higher contribution margins in SSI cases, and ICU admission led to greater deficits. Private insurance had a strong increasing effect on contribution margin at the 10th, 50th (median), and 90th percentiles of its distribution, leading to overall positive contribution margins for SSIs in Switzerland. The NHS England simulation with 3,893 patients revealed similar but less pronounced effects of SSI on contribution margin.

Depending on payer type, reimbursement systems with DRGs offer only minor financial incentives to the prevention of SSI.

To examine the relationship between unit-wide Clostridium difficile infection (CDI) susceptibility and inpatient mobility and to create contagion centrality as a new predictive measure of CDI.

Retrospective cohort study.

A mobility network was constructed using 2 years of patient electronic health record data for a 739-bed hospital (n = 72,636 admissions). Network centrality measures were calculated for each hospital unit (node) providing clinical context for each in terms of patient transfers between units (ie, edges). Daily unit-wide CDI susceptibility scores were calculated using logistic regression and were compared to network centrality measures to determine the relationship between unit CDI susceptibility and patient mobility.

Closeness centrality was a statistically significant measure associated with unit susceptibility (P < .05), highlighting the importance of incoming patient mobility in CDI prevention at the unit level. Contagion centrality (CC) was calculated using inpatient transfer rates, unit-wide susceptibility of CDI, and current hospital CDI infections. The contagion centrality measure was statistically significant (P < .05) with our outcome of hospital-onset CDI cases, and it captured the additional opportunities for transmission associated with inpatient transfers. We have used this analysis to create easily interpretable clinical tools showing this relationship as well as the risk of hospital-onset CDI in real time, and these tools can be implemented in hospital EHR systems.

Quantifying and visualizing the combination of inpatient transfers, unit-wide risk, and current infections help identify hospital units at risk of developing a CDI outbreak and, thus, provide clinicians and infection prevention staff with advanced warning and specific location data to inform prevention efforts.

Resistance to colistin, a last resort antibiotic, has emerged in India. We investigated colistin-resistant Klebsiella pneumoniae(ColR-KP) in a hospital in India to describe infections, characterize resistance of isolates, compare concordance of detection methods, and identify transmission events.

Retrospective observational study.

Case-patients were defined as individuals from whom ColR-KP was isolated from a clinical specimen between January 2016 and October 2017. Isolates resistant to colistin by Vitek 2 were confirmed by broth microdilution (BMD). Isolates underwent colistin susceptibility testing by disk diffusion and whole-genome sequencing. Medical records were reviewed.

Of 846 K. pneumoniae isolates, 34 (4%) were colistin resistant. In total, 22 case-patients were identified. Most (90%) were male; their median age was 33 years. Half were transferred from another hospital; 45% died. Case-patients were admitted for a median of 14 days before detection of ColR-KP. Also, 7 case-patients (32%) received colistin before detection of ColR-KP. All isolates were resistant to carbapenems and susceptible to tigecycline. Isolates resistant to colistin by Vitek 2 were also resistant by BMD; 2 ColR-KP isolates were resistant by disk diffusion. Moreover, 8 multilocus sequence types were identified. Isolates were negative for mobile colistin resistance (mcr) genes. Based on sequencing analysis, in-hospital transmission may have occurred with 8 case-patients (38%).

Multiple infections caused by highly resistant, mcr-negative ColR-KP with substantial mortality were identified. Disk diffusion correlated poorly with Vitek 2 and BMD for detection of ColR-KP. Sequencing indicated multiple importation and in-hospital transmission events. Enhanced detection for ColR-KP may be warranted in India.

Antibiotic-resistant organism (ARO) colonization rates in skilled nursing facilities (NFs) are high; hand hygiene is crucial to interrupt transmission. We aimed to determine factors associated with hand hygiene adherence in NFs and to assess rates of ARO acquisition among healthcare personnel (HCP).

HCP were observed during routine care at 6 NFs. We recorded hand hygiene adherence, glove use, activities, and time in room. HCP hands were cultured before and after patient care; patients and high-touch surfaces were cultured. HCP activities were categorized as high-versus low-risk for self-contamination. Multivariable regression was performed to identify predictors of hand hygiene adherence.

We recorded 385 HCP observations and paired them with cultures performed before and after patient care. Hand hygiene adherence occurred in 96 of 352 observations (27.3%) before patient care and 165 of 358 observations (46.1%) after patient care. Gloves were worn in 169 of 376 observations (44.9%). Higher adherence was associated with glove use before patient care (odds ratio [OR], 2.55; 95% confidence interval [CI], 1.44–4.54) and after patient care (OR, 3.11; 95% CI, 1.77–5.48). Compared with nurses, certified nurse assistants had lower hand hygiene adherence (OR, 0.31; 95% CI, 0.15–0.67) before patient care and physical/occupational therapists (OR, 0.22; 95% CI, 0.11–0.44) after patient care. Hand hygiene varied by activity performed and time in the room. HCP hands were contaminated with AROs in 35 of 385 cultures of hands before patient care (0.9%) and 22 of 350 cultures of hands after patient care (6.3%).

Hand hygiene adherence in NFs remain low; it is influenced by job title, type of care activity, and glove use. Hand hygiene programs should incorporate these unique care and staffing factors to reduce ARO transmission.

Nudging in microbiology is an antimicrobial stewardship strategy to influence decision making through the strategic reporting of microbiology results while preserving prescriber autonomy. The purpose of this scoping review was to identify the evidence that demonstrates the effectiveness of nudging strategies in susceptibility result reporting to improve antimicrobial use.

A search for studies in Ovid MEDLINE, Embase, PsycINFO, and All EBM Reviews was conducted. All simulated and vignette studies were excluded. Two independent reviewers were used throughout screening and data extraction.

Of a total of 1,346 citations screened, 15 relevant studies were identified. Study types included pre- and postintervention (n = 10), retrospective cohort (n = 4), and a randomized controlled trial (n = 1). Most studies were performed in acute-care settings (n = 13), and the remainder were in primary care (n = 2). Most studies used a strategy to alter the default antibiotic choices on the antibiotic report. All studies reported at least 1 outcome of antimicrobial use: utilization (n = 9), appropriateness (n = 7), de-escalation (n = 2), and cost (n = 1). Moreover, 12 studies reported an overall benefit in antimicrobial use outcomes associated with nudging, and 4 studies evaluated the association of nudging strategy with subsequent antimicrobial resistance, with 2 studies noting overall improvement.

The number of heterogeneous studies evaluating the impact of applying nudging strategies to susceptibility result reports is small; however, most strategies do show promise in altering prescriber’s antibiotic selection. Selective and cascade reporting of targeted agents in a hospital setting represent the majority of current research. Gaps and opportunities for future research identified from our scoping review include performing prospective randomized controlled trials and evaluating other approaches aside from selective reporting.

To report an outbreak of measles with epidemiological link between Hong Kong International Airport (HKIA) and a hospital.

Epidemiological investigations, patients’ measles serology, and phylogenetic analysis of the hemagglutinin (H) and nucleoprotein (N) genes of measles virus isolates were conducted.

In total, 29 HKIA staff of diverse ranks and working locations were infected with measles within 1 month. Significantly fewer affected staff had history of travel than non–HKIA-related measles patients [10 of 29 (34.5%) vs 28 of 35 (80%); P < .01]. Of 9 airport staff who could recall detailed exposure history, 6 (66.7%) had visited self-service food premises at HKIA during the incubation period, where food trays, as observed during the epidemiological field investigation, were not washed after use. Furthermore, 1 airport baggage handler who was admitted to hospital A before rash onset infected 2 healthcare workers (HCWs) known to have 2 doses of MMR vaccination with positive measles IgG and lower viral loads in respiratory specimens. Infections in these 2 HCWs warranted contact tracing of another 168 persons (97 patients and 71 HCWs). Phylogenetic comparison of H and N gene sequences confirmed the clonality of outbreak strains.

Despite good herd immunity with overall seroprevalence of >95% against measles, major outbreaks of measles occurred among HKIA staff having daily contact with many international pssengers. Lessons from severe acute respiratory syndrome (SARS) and measles outbreaks suggested that an airport can be a strategic epidemic center. Pre-exanthem transmission of measles from airport staff to HCWs with secondary vaccine failure poses a grave challenge to hospital infection control.