To investigate whether empiric carbapenem therapy, compared to empiric non-carbapenem therapy, was associated with improved clinical outcomes among hospitalized, non-intensive care unit (ICU) patients with extended-spectrum β-lactamase (ESBL)-producing Enterobacterales infections.

We performed a retrospective cohort study of adult, non-ICU patients admitted with ESBL-producing Enterobacterales infections. Primary outcome was time to clinical stability from the first empiric antibiotic dose. Secondary outcomes were early clinical response and 30-day all-cause hospital readmission. We used multivariate regression methods to examine time to clinical stability.

Of the 142 patients, 59 (42%) received empiric carbapenems and 83 (58%) received empiric non-carbapenems, most commonly ceftriaxone (49/83, 59%). Median age was 59 years. The most common infection source was urinary (71%). The carbapenem group had a higher proportion of patients who received antibiotics within 6 months of admission (55% vs 28%, P < .01) and history of ESBL (57% vs 17%, P < .01). There were no significant differences in hours until clinical stability between the carbapenem and non-carbapenem groups (22 (IQR: 0, 85) vs 19 (IQR: 0, 69), P = .54). Early clinical response (88% vs 90%, P = .79) and 30-day all-cause hospital readmission (17% vs 8%, P = .13) were similar between groups.

Among hospitalized non-ICU patients with ESBL-producing Enterobacterales infection, we found no difference in time to clinical stability after the first empiric antibiotic dose between those receiving carbapenems and those who did not. Our data suggest that empiric carbapenem use may not be an important driver of clinical response in patients with less severe ESBL-producing Enterobacterales infection.

To describe the epidemiology of healthcare-associated Clostridioides difficile infection (HA-CDI) in two Québec hospitals in Canada following the 2003 epidemic and to evaluate the impact of antibiotic stewardship on the incidence of HA-CDI and the NAP1/027 strain.

Time-series analysis.

Two Canadian tertiary care hospitals based in Montréal, Québec.

Patients with a positive assay for toxigenic C. difficile were identified through infection control surveillance. All cases of HA-CDI, defined as symptoms occurring after 72 hours of hospital admission or within 4 weeks of hospitalization, were included.

The incidence of HA-CDI and antibiotic utilization from 2003 to 2020 were analyzed with available C. difficile isolates. The impact of antibiotic utilization on HA-CDI incidence was estimated by a dynamic regression time-series model. Antibiotic utilization and the proportion of NAP1/027 strains were compared biannually for available isolates from 2010 to 2020.

The incidence of HA-CDI decreased between 2003 and 2020 at both hospitals from 26.5 cases per 10,000 patient-days in 2003 to 4.9 cases per 10,000 patient-days in 2020 respectively. Over the study period, there were an increase in the utilization of third-generation cephalosporins and a decrease in usage of fluoroquinolones and clindamycin. A decrease in fluoroquinolone utilization was associated with a significant decrease in HA-CDI incidence as well as decrease in the NAP1/027 strain by approximately 80% in both hospitals.

Decreased utilization of fluoroquinolones in two Québec hospitals was associated with a decrease in the incidence of HA-CDI and a genotype shift from NAP1/027 to non-NAP1/027 strains.

This study aimed to investigate the contamination status of hospital sinks with carbapenemase-producing Enterobacterales (CPE), the efficacy of daily cleaning with sodium hypochlorite, and the relationships between CPEs isolated from contaminated sinks and patients.

Pre/postintervention surveys of the CPE-contaminated sinks.

Hospital wards including pediatric intensive care unit in a children’s hospital.

Consenting CPE-colonized patients admitted between November 2018 and June 2021 in our hospital.

Environmental culture of 180 sinks from nine wards in our hospital was performed three times with an interval of 2 years (2019, 2021, 2023). Molecular typing of the isolated strains from the sinks and patients was performed. After the first surveillance culture, we initiated daily disinfection of the sinks using sodium hypochlorite.

Before the intervention, we detected 30 CPE-positive sinks in 2019. After the intervention with sodium hypochlorite, we observed a substantial decline in the number of sinks contaminated with CPE; 13 in 2021 and 6 in 2023. However, the intervention did not significantly reduce the number of CPE-contaminated sinks used for the disposal of nutrition-rich substances. The CPE isolates from the patients and those from the sinks of the wards or floors where they were admitted tended to have similar pulse-field gel electrophoresis patterns.

Contaminated sinks could be reservoirs of disseminating CPE to the patients. Daily disinfection of sinks with sodium hypochlorite may be effective in eliminating CPE, although the effect could be weaker in sinks with a greater risk of contact with nutrition-rich substances.

Prior studies evaluating the impact of discontinuation of contact precautions (DcCP) on methicillin-resistant Staphylococcus aureus (MRSA) outcomes have characterized all healthcare-associated infections (HAIs) rather than those likely preventable by contact precautions. We aimed to analyze the impact of DcCP on the rate of MRSA HAI including transmission events identified through whole genome sequencing (WGS) surveillance.

Quasi experimental interrupted time series.

Acute care medical center.

Inpatients.

The effect of DcCP (use of gowns and gloves) for encounters among patients with MRSA carriage was evaluated using time series analysis of MRSA HAI rates from January 2019 through December 2022, compared to WGS-defined attributable transmission events before and after DcCP in December 2020.

The MRSA HAI rate was 4.22/10,000 patient days before and 2.98/10,000 patient days after DcCP (incidence rate ratio [IRR] 0.71 [95% confidence interval 0.56–0.89]) with a significant immediate decrease (P = .001). There were 7 WGS-defined attributable transmission events before and 11 events after DcCP (incident rate ratio 0.90 [95% confidence interval 0.30–2.55]).

DcCP did not result in an increase in MRSA HAI or, in WGS-defined attributable transmission events. Comprehensive analyses of the effect of transmission prevention measures should include outcomes specifically measuring transmission-associated HAI.

Clostridioides difficile infection (CDI) is a common, healthcare-associated infection. However, in Japan, testing for CDI is infrequent, suggesting that its incidence may be underestimated. This study aimed to examine the implementation of a multifaceted, diagnostic stewardship (DS) for CDI in a small Japanese hospital during the coronavirus 2019 pandemic.

Before-after study.

A small Japanese community hospital.

Healthcare workers including physicians, nurses, and pharmacists.

A multifaceted intervention including (1) the addition of CD testing criteria to the hospital guidelines; (2) provision of a tutorial on CD testing to physicians, nurses, and pharmacists; (3) assessment by clinical pharmacists and nurses of the need for CD testing in patients with nosocomial diarrhea and issuance of recommendations for CD testing to physicians; (4) reporting of data on the CD testing rate and CDI incidence in the study center.

The CD testing rate increased before the pandemic (+0.16/10,000 patient-days (PD); P = .28), decreased significantly during the pandemic (−0.79/10,000 PD; P = .02), and then increased significantly immediately after the implementation of the intervention (+29.6/10,000 PD; P < .01). Similarly, the CDI incidence increased significantly before the pandemic (+0.26/10,000 PD; P = .02) and decreased significantly during the pandemic (−0.49/10,000 PD; P = .01). Implementation of the intervention resulted in an immediate and significant increase in the CDI incidence (+6.2/10,000 PD; P < .01).

Multifaceted DS involving multidisciplinary specialists was effective in improving CD testing, suggesting that appropriate testing can contribute to diagnosing CDI accurately.

Antimicrobials are frequently used for palliation during end-of-life care, but adverse effects, such as antimicrobial resistance, are a concern. Shared decision-making is beneficial in end-of-life care conversations to help align antimicrobial-prescribing with patient preferences. However, there is limited data regarding optimal incorporation of antimicrobial-prescribing discussions into shared decision-making conversations. We explored healthcare provider, patient, and support caregiver (eg, family member/friend) perceptions of barriers and facilitators to discussing antimicrobial-prescribing during the end-of-life period.

Qualitative study.

Healthcare providers; palliative care/hospice care patients/caregivers.

We conducted semi-structured interviews on shared attitudes/beliefs about antimicrobial-prescribing during end-of-life patient care at one acute-care and one long-term-care facility. Interviews were analyzed for thematic content.

Fifteen providers and 13 patients/caregivers completed interviews. Providers recognized the potential benefit of leveraging shared decision-making to guide antimicrobial-prescribing decisions. Barriers included limited face-to-face time with the patient and uncertainty of end-of-life prognosis. Patients/caregivers cited trust, comprehension, and feeling heard as important characteristics which act as facilitators in fostering effective shared decision-making around antimicrobial use. Communication in which providers ensure patients are involved in shared decision-making discussions could be increased to ensure patients and their providers develop a mutually agreeable care plan.

Shared decision-making is a practice that can guide antimicrobial-prescribing decisions during end-of-life care, thus potentially minimizing antimicrobial-related adverse effects. Our findings highlight opportunities for increased shared decision-making around antimicrobial use during end-of-life care. Interventions designed to address the identified barriers to shared decision-making have the potential to improve antimicrobial-prescribing practices at end-of-life.

Real-time reverse-transcriptase polymerase chain reaction (RT-PCR) has been the gold standard for diagnosing coronavirus disease 2019 (COVID-19) but has a lag time for the results. An effective prediction algorithm for infectious COVID-19, utilized at the emergency department (ED), may reduce the risk of healthcare-associated COVID-19.

To develop a prototypic prediction model for infectious COVID-19 at the time of presentation to the ED.

Retrospective cohort study of all adult patients admitted to Singapore General Hospital (SGH) through ED between March 15, 2020, and December 31, 2022, with admission of COVID-19 RT-PCR results. Two prediction models were developed and evaluated using area under the curve (AUC) of receiver operating characteristics (ROC) to identify infectious COVID-19 patients (cycle threshold (Ct) of <25).

Total of 78,687 patients were admitted to SGH through ED during study period. 6,132 of them tested severe acute respiratory coronavirus 2 positive on RT-PCR. Nearly 70% (4,226 of 6,132) of the patients had infectious COVID-19 (Ct<25). Model that included demographics, clinical history, symptom and laboratory variables had AUROC of 0.85 with sensitivity and specificity of 80.0% & 72.1% respectively. When antigen rapid test results at ED were available and added to the model for a subset of the study population, AUROC reached 0.97 with sensitivity and specificity of 95.0% and 92.8% respectively. Both models maintained respective sensitivity and specificity results when applied to validation data.

Clinical predictive models based on available information at ED can be utilized for identification of infectious COVID-19 patients and may enhance infection prevention efforts.

This study aimed to investigate and contain a cluster of invasive candidiasis cases caused by fluconazole-resistant Candida parapsilosis (FRC) in a neonatal intensive care unit.

Active surveillance was initiated. Direct observations of hand-hygiene compliance (HHC) among staff were conducted before and after the implementation of hand-hygiene (HH) education. Thirty-five environmental cultures were obtained. Phylogenetic analysis of FRC was performed using Fourier-transform infrared spectroscopy and microsatellite genotyping.

A total of 14 patients (mean birth weight = 860 g, gestational age = 25 weeks) infected with FRC were identified using the fully automated analyzer, including 5 with clinical infection (three with catheter-related bloodstream infection, one with cutaneous infection, and one with fatal peritonitis) and 9 with colonization. The HHC rate in nurses before performing a sterile or aseptic procedure significantly improved after the HH education (P < .05). Sinks near the patients were contaminated with FRC. All FRC strains were confirmed to be susceptible to fluconazole using the CLSI method, and the microdilution procedure indicated a trailing effect. Phylogenetic analysis showed that all the fluconazole-trailing isolates from patients were clustered together and had the same genotype. Sinks were successfully decontaminated using accelerated hydrogen peroxide and drainage pipes were replaced. Ultraviolet-C decontamination was applied in the milk preparation room. No new cases were detected after the education and disinfection interventions.

Sinks are an important reservoir of C. parapsilosis. Active surveillance, environmental hygiene, and constant staff education on maintaining a high level of HHC are necessary to limit the spread of C. parapsilosis.

Assess whether direct inoculation of ascites into blood culture bottles would improve ascites culture yield.

Pre-post-study.

The study was performed at a quaternary academic medical center in Houston, Texas, including all inpatient and emergency department encounters.

Ascites cultures collected from November 2020 to December 2022 were reviewed and screened for spontaneous bacterial peritonitis. Patients were excluded if a prior ascites culture from the same patient was already included in the study or if there was evidence of secondary bacterial peritonitis.

In the pre-intervention period, ascites cultures were collected into a sterile container and inoculated onto/into solid and liquid media. In the post-intervention period, ascites cultures were instead directly inoculated into bioMérieux© blood culture bottles at the bedside.

114 patients met inclusion and exclusion criteria, 61 pre-intervention and 53 post-intervention. Overall ascites culture positivity was 15.8% (18/114), 11.5% (7/61) pre-intervention vs 20.8% (11/53) post-intervention. After adjusting for confounders, the intervention had a trend toward a significant effect on ascites culture positivity (P = 0.077). No significant differences were seen in time to positivity, hospital length of stay, or 30-day readmission.

Direct inoculation of ascitic fluid into blood culture bottles led to a small increase in culture yield but lacked statistical significance. This lack of significance may be due to the study being underpowered. Further studies are required to investigate if this is due to procedural inefficiencies (eg, inadequate inoculation volumes) or pragmatic clinical practice considerations (ie, high rates of pre-culture antibiotics).

This study aimed to assess the actual burden of antibiotic use among end-of-life (EOL) patients in South Korea and to compare trends between cancer and non-cancer decedents.

Population-based mortality follow-back study.

Data from the Korean National Health Insurance Database, covering the period from January1, 2006, to December 31, 2018, provided for research by the National Health Insurance Service (NHIS), were used.

All decedents from 2006 to 2018 were included and categorized as cancer decedents or non-cancer decedents.

Annual antibiotic consumption rates and prescription rates were calculated, and Poisson regression was used to estimate their trends.

Overall antibiotic consumption rates decreased slightly among decedents in their final month with a less pronounced annual decrease rate among cancer decedents compared to non-cancer decedents (0.4% vs 2.3% per year, P <.001). Over the study period, although narrow spectrum antibiotics were used less, utilization and prescription of broad-spectrum antibiotics steadily increased, and prescription rates were higher in cancer decedents compared to non-cancer controls. Specifically, carbapenem prescription rates increased from 5.6% to 18.5%, (RR 1.087, 95% CI 1.085–1.088, P <.001) in cancer decedents and from 2.9% to 13.2% (RR 1.115, 95% CI 1.113–1.116, P <.001) in non-cancer decedents.

Our findings show that patients at the EOL, especially those with cancer, are increasingly and highly exposed to broad-spectrum antibiotics. Measures of antibiotic stewardship are required among this population.

Central line-associated bloodstream infections (CLABSIs) harm children. Insertion and maintenance bundles have significantly reduced CLABSIs, but infections still occur. The objective was to develop bedside infection prevention (IP) rounds and evaluate their impact on CLABSI rates.

This quality improvement project was initiated sequentially in the neonatal intensive care unit (NICU) and pediatric intensive care unit (PICU) of a large academic children’s hospital. IP rounds, interdisciplinary discussions led by the hospital epidemiologist and unit nursing leader with the bedside nurse, occurred weekly for patients with central lines. Discussions included strategies to optimize line maintenance and identify and mitigate patient-specific infection risks. Concerns and recommendations were communicated with the clinician. CLABSIs were identified by prospective surveillance using standard definitions. The change in CLABSIs over time was analyzed using days-between-events charts (g chart).

IP rounds included 3,832 patients in the NICU and 1,322 patients in the PICU. Opportunities were identified to reduce line access and protect the dressing from contamination. The average days between CLABSIs in the NICU increased from 41 days to 54 days after IP rounds began. The longest time between CLABSIs was 362 days. In the PICU, the average days between CLABSIs increased from 53 to 91 days. The longest time between CLABSIs was 398 days.

IP rounds reduced CLABSIs in the NICU and PICU by reinforcing best practices, encouraging proactive strategies, and fostering communication between members of the healthcare team.