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Background: Wastewater-based epidemiology has demonstrated effectiveness in monitoring trends of viral infections at the city, state, and national levels. It captures data independent of testing intensity, providing a comprehensive biological sample of pathogens excreted in all secretions, that is unaffected by individual testing behaviors. Traditional healthcare-associated infection surveillance relies on case-based approaches, which can be resource-intensive, prone to misclassification, and may miss patients who are colonized. We aimed to evaluate the feasibility of implementing wastewater-based epidemiology in an acute care hospital for monitoring pathogens relevant to infection prevention and control. Methods: In this pilot study, we deployed a Teledyne ISCO 5800™ wastewater autosampler to collect weekly composite 1000 mL samples (15 mL every 151 minutes) from the final Stanford Hospital outflow point before wastewater merged with the community system. Wastewater samples were processed within 48 hours of collection. The solid phase was separated via centrifugation, followed by nucleic acid extraction employing silica-based purification techniques optimized for efficient inhibitor removal. Droplet digital PCR was conducted targeting pathogens previously validated by the WastewaterSCAN program (https://www.wastewaterscan.org/en/pathogens). We compared hospital wastewater nucleic acid concentrations with the number of positive tests/cultures at Stanford Hospital during the same period and with Wastewaterscan community wastewater data. Results: We collected three weekly composite samples: Jun 20–26, Jul 10–17, and Jul 18–25. Challenges included the location of the final outflow, and the autosampler’s size (132 x 74 x 84 cm and 88.5 kg). The outflow point was situated in a high-traffic area for patients and staff, requiring barricades to ensure safety and prevent interference with sampling equipment. In terms of interpreting results, viral nucleic acid concentrations (e.g., influenza, SARS-CoV-2) appeared to parallel the number of clinical cases and were similar to community wastewater trends (Figure 1). Most antimicrobial resistance genes, including vanA (Figure 2) and carbapenemase genes (KPC, NDM, OXA-48, VIM) (Figure 3), showed limited alignment with clinical cases; however, mecA exhibited some alignment (Figure 2). Hospital wastewater had higher resistance gene concentrations than community wastewater from San Mateo County (Figure 4). Conclusion: Continuous collection of hospital wastewater proved challenging, mainly from logistical issues such as equipment size and access limitations. Clinical respiratory virus trends appeared to be reflected in wastewater data. However, trends for antimicrobial resistance genes may be influenced by additional factors, such as the number of colonized patients, bacterial load in the hospital sewage system, hospital antimicrobial use, and antibiotic residues in wastewater.
Introduction: Enterococci are the third most common healthcare-associated pathogen, with 30% of isolates resistant to vancomycin (VRE). Resistance is often conferred by the vanA gene cluster on transposon Tn1546 and is frequently plasmid-borne. The suspected role of person-to-person transmission prompted the recommendation for VRE isolation precautions in 1995. However, quasi-experimental studies in hospitals discontinuing these precautions found no significant increases in VRE infections or bacterial clone spread using short-read whole genome sequencing (WGS). We used long-read WGS to analyze vanA plasmid transmission dynamics after discontinuing isolation precautions for VRE at Stanford University Hospital. Methods: This study was conducted at Stanford University Hospital, an 800-bed quaternary referral and transplant center. Routine contact precautions for VRE were discontinued on October 1, 2021. Blood culture Enterococcus faecalis and E. faecium isolates collected during 2021 (prior to and following discontinuation) were included, along with additional isolates retrieved from January–October 2023. Bacterial whole genome sequencing with long-read nanopore technology was performed. Custom analyses were performed on the assembled genomes. Patient data were collected retrospectively. Results: We retrieved 105 blood culture isolates (36.2%) from the isolation period (January–October 2021) and 185 isolates (63.8%) from the no isolation period (October–December 2021, January–October 2023), representing 202 unique patients. Patient characteristics and microbiological findings are shown in Table 1. Only 4.3% (7/171) of E. faecalis and 70.5% (84/119) of E. faecium isolates were vancomycin-resistant. Long-read WGS revealed no clustering between the isolation and no isolation periods. (Figure 1A and B); however, a dominant E. faecium ST117 cluster was seen, while E. faecalis showed greater diversity (Figure 1C). There were only four pairs of putative transmissions Conclusion: The discontinuation of contact isolation precautions at Stanford Hospital did not result in an increase in genetically related Enterococci or genetically related vanA plasmids among patients with Enterococcal bacteremia.
Background: Lower respiratory tract infections (LRTI) are a leading cause of pediatric mortality. Treatment typically involves empirical antibiotics, followed by de-escalation based on cultures, which are often negative. The BioFire® Pneumonia PCR panel detects pathogens rapidly, allowing for potentially faster optimization of antimicrobial therapy. Limited data exists on this panel in pediatrics, especially for bronchoalveolar lavage (BAL) samples. We hypothesized that patients with LRTI evaluated using the BAL PCR panel (PCR cohort) had shorter times to results and targeted therapy compared to those with BAL cultures alone (control cohort). Method: We conducted a retrospective study of patients aged 0–18 admitted to NYU Langone Manhattan with LRTI. The PCR cohort included patients from August 1, 2021, to November 1, 2023, who underwent both BAL culture and PCR testing. The control cohort included patients from August 1, 2017, to November 1, 2019, who had BAL cultures alone. The primary outcome was time to targeted therapy, defined as the time from culture collection to escalation or de-escalation. Results: A total of 280 patients were included (PCR n=172, Control n=108). The cohort had a median age of 3 years, with asthma (35% vs. 51%) and bronchiectasis (30% vs. 39%) being the most common comorbidities. Immunocompromised patients accounted for 7% of the PCR cohort and 6% of the control cohort. Most patients were on room air; 16% of the PCR group and 9% of the control group were intubated. Infectious Diseases was consulted more often in the PCR group (30% vs. 19%). PCR detected organisms faster compared to culture alone (4 vs. 25–26 hours). Discordant results between PCR and culture were 57%, with 81% due to additional bacteria detected by PCR. Stenotrophomonas maltophilia was the most common organism detected by culture but not included in the PCR panel. Time to targeted therapy was significantly shorter in the PCR group compared to culture group (0 vs. 1 day, p=0.003). Time to de-escalation was numerically faster in the PCR compared to control group (2 vs. 3 days, p=0.061). Fewer PCR patients received MRSA agents (34% vs. 55%, p=0.001). Rates of escalation, prior antibiotic use, and adverse outcomes were similar. Conclusion: The BioFire FilmArray Pneumonia Panel provides faster results and may aid in optimizing therapy in pediatric patients with LRTI.
Background: Most people in the US lack access to infectious disease (ID) expertise, with 80% of counties lacking an ID physician. This is problematic as in-person ID consultation has been shown to improve clinical outcomes such as mortality with certain invasive infections, with Staphylococcus aureus bacteremia (SAB) as the paradigm. Telemedicine consultation has emerged as a tool to expand access in rural and underserved communities though its impact on clinical outcomes is less well established. This study characterizes the impact of a Tele-ID program in improving care for patients with SAB at a network of academic-affiliated rural hospitals that do not have access to in-person ID consultation. Methods: This was a retrospective cohort study of patients with SAB who were initially evaluated at 3 academic-affiliated rural hospitals between 7/1/22 and 6/30/24. A cohort of patients who received a Tele-ID consult was compared against a cohort that did not. The primary outcome was adherence to the standard of care for SAB, defined as documentation of clearance of blood cultures, receipt of an echocardiogram, and receipt of an appropriate course of antibiotics. Secondary outcomes included clinical outcomes such as mortality and readmission rates. Results: A total of 260 discrete episodes of SAB were screened for inclusion, with 122 episodes meeting inclusion criteria. Seventy five patients (61.5%) who received a Tele-ID consult were compared against 47 patients (38.5%) who did not. Patient characteristics were overall similar in these groups, though those receiving Tele-ID consultation were more likely to have end-stage renal disease (15% vs 0%, p < .01) and indwelling hardware (56% vs 21%, p < .01). Tele-ID consultation was associated with a higher likelihood of receiving standard of care for SAB (91% vs 15%, p < .01). This finding was consistent across all hospitals and among the individual components of the primary outcome. In addition, Tele-ID consultation was associated with significantly decreased SAB-related 30-day mortality (7 vs 24%, p < .01) and SAB-related 90-day mortality (8 vs 25%, p < .01). No significant difference was observed in rates of readmission or relapsed bacteremia. Conclusion: In this retrospective cohort study of 122 patients with SAB cared for in rural, academic-affiliated hospitals, Tele-ID consultation was associated with a significantly increased likelihood of receiving standard of care and decreased mortality. This data will inform policy at regional hospitals, such as supporting a mandatory ID consult for SAB and implementation of a SAB bundle.
Background: The Agency for Healthcare Research and Quality Safety Program for MRSA Prevention Surgical Services cohort aimed to reduce surgical site infections (SSIs) and prevent methicillin-resistant Staphylococcus aureus (MRSA) in teams performing surgeries at high risk for infection with and high morbidity due to MRSA (cardiac, knee or hip replacement, and spinal fusion) using evidence-based infection prevention interventions and the Comprehensive Unit-based Safety Program (CUSP) framework. We report process and outcome measures associated with program participation. Methods: The Surgical Services Safety Program for MRSA Prevention was implemented from January 2023 to June 2024. The aim was to increase teamwork and collaboration, reinforce safety culture, implement evidence-based infection prevention practices, and decrease SSIs and MRSA. The project team provided 22 live webinars, supporting materials, and other tools to assist surgical teams (Table 1). Teams were also assigned an implementation advisor who provided support through monthly coaching calls.
Teams submitted baseline and endline information on patient safety culture and on infrastructure at the team- and hospital-level, as well as monthly data regarding process measures and SSIs. Teams submitted SSI data from 12 months prior to the start of the program and for 18 months after program implementation. Changes were assessed using pre-post comparisons with Chi-squared test and linear mixed effect models with random intercept. Results: 104 surgical teams (18 cardiac, 19 neurosurgical spinal fusion, 16 orthopedic spinal fusion, 51 knee/hip replacement) from 63 hospitals completed the program. Significant improvements in team-based process measures of surgical team infrastructure (Figure 1) and in teams’ reporting that patients received evidence-based practices (Figure 2) were observed across several areas from baseline to endline, including preoperative decolonization, appropriate antibiotic prophylaxis, and intraoperative infection prevention procedures. While SSI rates did not significantly change, the observed 23% decrease in overall deep or organ space SSI rates approached statistical significance (95% CI -0.46, 0.01) (Table 2 and Table 3). Conclusions: The AHRQ Safety Program for MRSA Prevention supported implementation of evidence-based infection prevention practices to prevent MRSA and SSIs in high-risk surgeries. Participating teams showed improvements in team-based process measures and observed a reduction in deep or organ space SSI rates.
Background: Public health communications during the COVID-19 pandemic demonstrated the value of web-based dashboards displaying trends in viral transmission to help inform individual and public health decision-making. However, these dashboards were often created without direct public engagement and lacked community-level data. We sought to bridge this gap by leveraging the data and resources of a large academic health center to create an extensible, dynamic respiratory viral trends dashboard incorporating feedback from community stakeholders. Method: Data on COVID-19, influenza and respiratory syncytial virus (RSV) testing and hospitalizations were programmatically collected from multiple sources, including the North Carolina Department of Health and Human Services, Centers for Disease Control and Prevention, and the healthcare system’s aggregated statistics and were presented on a web-based dashboard. Key statistics including test positivity rate, case counts, and trends were calculated. Projections were estimated using statistical and Bayesian semi-parametric models where sufficient data were available. Community stakeholders were identified through public health departments and the health facility’s community engagement department. The dashboard was presented to stakeholders quarterly over two years and electronic surveys solicited anonymous feedback after each meeting. A team of data scientists and infectious disease physicians served as the leads for dashboard development, meeting bi-weekly to address feedback and iterate on visual presentation. Result: The initial web-dashboard focused on COVID-19 variants and rapidly expanded to include RSV and influenza trends due to the predicted “tripledemic” in the 2022 respiratory viral season (Figures 1-7). The data were presented and allowed for comparison of national, state, and local disease dynamics and with data inputs updated weekly through an automated R program. Stakeholders included representatives from 6 county health departments, 2 colleges/universities, 2 community groups, and urgent care medical directors. A vast majority (17/18) felt that the knowledge gained was useful and not available to them from other sources, with 28% (5/18) indicating that the information presented informed practice, such as masking protocols or vaccine campaigns. The dashboard went through 3 major revisions in response to community stakeholder feedback. Conclusion: We describe the implementation of a community stakeholder-informed, web-based dashboard for the surveillance and forecasting of key respiratory viral pathogens utilizing national, regional and facility level data to help inform crucial decision-making for local health facilities and public health groups to curb transmission and spread. The framework of this platform can be built upon to include timely monitoring and public communication of the epidemiologic behavior of emerging pathogens in the community.
Background: State-level hospital comparative antibiotic usage rates can highlight opportunities for interventions to optimize antimicrobial stewardship (AS). We sought to characterize antibiotic usage rates for Nebraska hospitals stratified by hospital size and rurality. Methods: NHSN antibiotic use (AU) data reported from September 2023 to August 2024 was extracted. Hospitals reporting adult data for any antibiotics of interest were included in analysis. Data from all units reported by the hospital were included. Hospital sizes were categorized by number of beds reported to NHSN: critical access (≤25 beds), medium (26-150 beds), and large (>150 beds). Rurality was defined using the USDA rural urban commuting area codes: urban (1-3), semi-urban (4-6), and rural (7-10). AU rate was calculated using antimicrobial days of therapy over 1,000 days present. Pooled AU rates were used to provide a state rate by covariates and antibiotics. Descriptive statistics were used to describe prescribing patterns. A negative binomial regression model was used to understand the effect of hospital size and rurality on rate and one-way ANOVA to test significance. Results: AU data was analyzed for 51 facilities including 7 large hospitals (14%), 16 medium-sized hospitals (31%), and 28 critical access hospitals (55%). Of these, 27 facilities (53%) were located in rural and 9 (18%) in semiurban areas (Table 1). The top 5 antibiotics used were cefazolin, ceftriaxone, piperacillin/tazobactam, vancomycin, and cefepime (Figure 1). Although, there were no significant variations in total AU based on hospital size and rurality, some significant differences were noted when broken down by specific antibiotics (Figures 2 and 3). Critical access hospitals reported 1.8 times higher AU rate for ceftriaxone [95% CI: 1.2, 2.7], 2.2 times the rate for fluoroquinolones [95% CI: 1.3, 3.7], and 2.3 times the rate for azithromycin [95% CI: 1.4, 3.7], compared to large hospitals. Similarly compared to urban hospitals, rural hospitals reported 1.9 times higher AU rate for ceftriaxone [95% CI: 1.4, 2.5], 2.3 times the rate for fluoroquinolones [95% CI: 1.6, 3.4], and 2.2 times the rate for azithromycin [95% CI: 1.6, 3.2]. No significant difference was noted in the use of any antibiotics when comparing semiurban to urban and medium to large size hospitals. Conclusions: Significant variation exists in use of some antibiotics based on the hospital size and rurality. NHSN AU data can be leveraged to identify potential AS targets across various hospital settings.
Background: Crisp Regional Hospital (CRH) in Georgia initiated a quality improvement project to address the excessive and inappropriate urine culture orders among inpatients. The project aimed to reduce these orders by at least 30% by June 2024, targeting the prevalent issues of increased healthcare costs and antibiotic misuse stemming from unnecessary testing. Methods: Using the Institute for Healthcare Improvement (IHI) framework, the project implemented a series of multidisciplinary strategies. These included nursing education on proper urine collection, policy updates to facilitate accurate specimen collection from specific patient groups, medical staff education on appropriateness of urine test ordering and a change in reflex criteria for urine testing. Data was analyzed using statistical process control and T-tests to assess the impact of the interventions. Results: The intervention led to a reduction in urine tests from 618 to 570. Tests reflexed to culture decreased significantly from 34.63% to 18.95% (p Conclusion: The quality improvement initiative at CRH significantly reduced unnecessary urine cultures, optimized resource use, and maintained diagnostic integrity. The interventions implemented were effective and scalable, demonstrating substantial cost savings and enhanced patient care quality. Further efforts will focus on analyzing the impact of removing pre-checked orders and implementing mandatory testing indications to continue improving urine testing practices.
Background: The National Healthcare Safety Network (NHSN) Antibiotic Use (AU) Option aids hospital antimicrobial stewardship programs (ASPs) by facilitating tracking and reporting of AU data. In 2021, the Tennessee Department of Health (TDH) launched an AU data quality project to improve reporting accuracy. Quarterly reports are generated, assessing data across 15 quality flags, such as reporting antimicrobial days when days present (DP) are zero or drug-route mismatches. Flags also highlight significant outliers, including DP or AU rates outside the median ±2 interquartile ranges compared to the prior year. Reporting facilities receive actionable solutions for flagged concerns. Method: Data from AU quality flag reports generated by the NHSN AU Option for Tennessee facilities (2021–2023) were analyzed in this cross-sectional study. The analysis summarized the frequency and distribution of flagged issues across facilities and time. Archived data were utilized, excluding updates facilities made after quarterly reports. Quarterly flags per category were calculated for each facility, with total flags compiled annually to determine category frequency and percentage. Additionally, the number of distinct facilities contributing to the annual flag count was evaluated, providing insights into data quality trends across the study period. Result: From 2021 to 2023, 97 facilities submitted data to the NHSN AU Option, resulting in 7336 flags identified in the AU quality reports (Figure 1). The most frequent flag was “location-level AU rate greater than outlying upper boundary” (n=1677, 22.9%), reported by 67 facilities and the highest reported in 2023 (n=722, 23.8%). The second was “location-level DP greater than outlying upper boundary” (n=1588, 21.6%), reported by 68 facilities and highest in 2021 (n=547, 23.5%). The most frequent non-outlier-based quality issue was “antimicrobial days reported for any drug when DP were reported as zero” (n=439, 6.0%) followed by “antimicrobial days for a single drug greater than DP” (n=48) Conclusion: The study reveals data quality concerns in AU reporting among Tennessee facilities. Flags with changes in “Location-Level Days Present” and “AU Rate” outliers being prominent across the study period. These findings underscore the need for continuous monitoring and targeted feedback to enhance data accuracy, as well as a need for antimicrobial stewardship personnel to be able to identify and address changes in prescribing patterns and patient populations efficiently within their facilities. Addressing recurring challenges identified can improve AU data reliability, supporting more effective antimicrobial stewardship and better patient care outcomes.
Background: Older adults are prescribed more antibiotics than younger populations and face increased risks of antibiotic-related adverse events. Identifying high-volume prescribers (HVPs) through Medicare Part D (MPD) datasets and engaging them through targeted intervention, such as peer-comparison audit and feedback, is a way to impact antibiotic prescribing. Methods: We analyzed the 2022 publicly available Centers for Medicare & Medicaid Services MPD Prescribers by Provider dataset to summarize the data overall and identify HVPs within each specialty. HVPs were classified as prescribers in the top 10% of antibiotic prescribing by volume within their specialty. Prescribers with 1,316 Minnesota prescribers in 2022 were considered HVPs (top 10% by volume by specialty). After removing certain specialties and those with low prescribing rates, 995 HVPs met criteria and were mailed feedback letters, with 4.32% (43 letters) lost to follow-up. These HVPs were responsible for 28.7% of antibiotic prescriptions for Minnesota’s MPD beneficiaries in 2022. The median antibiotic prescribing rate of these HVPs was 1.8 times higher than that of lower-volume prescribers (Table 1) (p To date, 18 letter recipients responded to the feedback survey, with 22.2% intending to review their current prescribing habits, 22.2% reflecting that there is room for improvement in their prescribing, and 55.6% have accessed or intend to access AS resources. Conclusion: This audit and feedback initiative demonstrated that the MPD dataset can be used as a low-cost method to provide peer-comparison feedback to HVPs. By reaching providers responsible for nearly 30% of antibiotic prescriptions among MPD beneficiaries in Minnesota, this intervention has potential to influence prescribing behaviors. Further work will evaluate feedback and focus on specific provider specialties and drug classes.
Background: The Centers for Disease Control and Prevention (CDC) Core Elements of Antibiotic Stewardship for Health Departments includes tracking and reporting of antibiotic use (AU). To support outpatient AU tracking and reporting, the Wisconsin Department of Health Services (DHS) leveraged all-payers’ claims data to create health care organization-specific outpatient AU dashboards with benchmarked measures. Methods: DHS contracted with the Wisconsin Health Information Organization’s to access their database to review all payers’ claims data from 2018–2023, which included medical encounter and pharmaceutical claims. Visits were included if they occurred at a clinic (in-person or virtual), urgent care, or emergency department in Wisconsin. Antibiotic visits were defined as an outpatient visit associated with a filled oral, systemic antibiotic prescription ordered up to three days after the encounter. Antibiotic visits were normalized by all outpatient visits as a rate per 1,000 visits. A quality measure of antibiotic visits for respiratory tract infection (RTI) was developed using the CDC’s tier 3 ICD-10 codes representing cough, upper RTI, or bronchitis without co-occurring ICD-10 code for other infection. Antibiotic visit rates were then summarized at the health care organization level, with additional stratification by place of service, diagnosis, patient age, and provider type. Results: From 2018–2023, there were over 59 million outpatient visits in Wisconsin by over 20,000 different clinicians from 57 organizations. Statewide benchmarks were developed for all diagnoses and RTI antibiotic visit rates (Tables 1 and 2). Visits by surgeons and advanced practitioners had the highest rates of antibiotic prescribing for tier 3 RTIs; rates were similar across places of service. Rates per individual prescriber were visually compared to the statewide and organization benchmarks within dashboards (Figure 1). Conclusion: All-payers’ claims data provides a statewide data source to develop antibiotic visit rates, including a quality measure for visits associated with RTI. Overlying statewide and organizational medians provides a benchmark to identify outliers for further stewardship interventions. Piloting these dashboards will help improve access to AU data.
Background: There is limited evidence to guide the diagnosis and treatment of urinary tract infections (UTIs) in men. We hypothesized that lower clinician confidence in ability to correctly diagnose or treat UTIs in men would be associated with increased antibiotic treatment duration. Methods: We surveyed clinicians’ knowledge and confidence in diagnosing and treating UTIs in outpatient men as well as their intention to prescribe a specific duration of antibiotics. We distributed the survey to outpatient primary care and emergency medicine providers, urologists, and internal medicine residents. We collected demographics on professional role (physician-attending, physician-trainee, advanced practice professionals [APPs]), specialty, and years in practice. Surveys were distributed on paper and electronically. Analysis involved t-test and ANOVA for continuous variables and Chi-squared for categorical variables as appropriate. Multiple logistic regression analyses were performed using the outcome variable of antibiotic treatment duration, categorized as appropriate (5-7 days) or inappropriate (> 7 days). Results: 186 of 363 distributed surveys were completed (51% response rate). Fifteen surveys were excluded due to the respondent specialty (e.g., dermatology, neurology, etc.), leaving 171 surveys for analysis. Of these, 60% were from trainees, 26% attendings, and 14% APPs (Figure 1). Most physicians (Figure 2) were internal medicine trained (81%), with a smaller proportion of family medicine (8%), urology (6%), and emergency medicine (5%). 14% of respondents reported an intention to treat UTIs in men for longer than 7 days (Figure 3). Lower clinician confidence in ability to correctly diagnose male UTI was associated with longer intended antibiotic treatment durations (Odds Ratio [OR] 0.42, Confidence Interval [CI] 0.19-0.91, p = 0.03). This association was independent of professional role, specialty, and years in practice. Lower clinician confidence in ability to correctly treat male UTI was not significantly associated with longer intended treatment durations (OR 0.46, CI 0.21-1.03, p = 0.06) on univariate analysis but was significantly associated when adjusted for years since graduation (OR 0.40, CI 0.17-0.96, p = 0.04). Confidence in diagnosis (Figure 4) was significantly different between professional roles, with trainees significantly less confident (median ± standard deviation = 3.1 ± 0.56) than attendings (3.7 ± 0.47, p) Conclusions: Lower confidence among clinicians in either diagnosis or treatment of UTIs in men was associated with intention to prescribe longer antibiotic courses. Future studies that address the evidence gaps in diagnosis and management of UTI in men may improve clinician confidence and thus reduce unnecessarily long durations of antibiotics.
