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Climate change is driven primarily by humanity’s use of fossil fuels and the resultant greenhouse gases from their combustion. The effects of climate change on human health are myriad and becomingly increasingly severe as the pace of climate change accelerates. One relatively underreported intersection between health and climate change is that of infections, particularly antibiotic-resistant infections. In this perspective review, the aspects of climate change that have already, will, and could possibly impact the proliferation and dissemination of antibiotic resistance are discussed.

Antibiotic resistance is a public health emergency, with ten million deaths estimated annually by the year 2050. Water systems are an important medium for the development and dissemination of antibiotic resistance from a variety of sources, explored in this perspective review. Hospital wastewater and wastewater systems more broadly are breeding grounds for antibiotic resistance because of the nature of their waste and how it is processed. Corporations from various sectors contribute to antibiotic resistance in many direct and indirect ways. Pharmaceutical factory runoff, agricultural antibiotic use, agricultural use of nitrogen fertilizers, heavy metal pollution, air pollution (atmospheric deposition, burning of oil and/or fossil fuels), plastic/microplastic pollution, and oil/petroleum spills/pollution have all been demonstrated to contribute to antibiotic resistance. Mitigation strategies to reduce these pathways to antibiotic resistance are discussed and future directions hypothesized.

Background Air changes per hour (ACH) in operating rooms (ORs) are energy intensive, and optimal air change settings are not known. Objectives We sought to explore whether there is a relationship between surgical site infections (SSIs) across states based on their state-mandated ACHs. Design Ecological, descriptive, cross-sectional study of publicly reported SSI data in the United States. Methods Wilcoxon test was used to investigate differences between SSI rates for specific surgery types between ACH mandate levels (15 and 20 ACH). Uni- and multivariable Poisson models at the state level were fitted to estimate differences in SSI rates for each surgery type. Results OR ACH mandates and SSIs were positively correlated for C-sections and spinal fusion; negatively correlated for colon and laminectomy surgery. Conclusion For most surgery types, there is no correlation between state-mandated OR ACH. Further studies are needed to determine what changes to mandates can be made safely and effectively.

The main objective of the study was to assess whether augmented renal clearance was a risk factor for mortality in a cohort of patients with Enterobacteriaceae sepsis, severe sepsis, or septic shock that all received appropriate antimicrobial therapy within 12 hours. Using a retrospective cohort from Barnes-Jewish Hospital, a 1,250-bed teaching hospital, we collected data on individuals with Enterobacteriaceae sepsis, severe sepsis, and septic shock who received appropriate initial antimicrobial therapy between June 2009 and December 2013. Clinical outcomes were compared according to renal clearance, as assessed by Modification of Diet in Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formulas, sepsis classification, demographics, severity of illness, and comorbidities. We identified 510 patients with Enterobacteriaceae bacteremia and sepsis, severe sepsis, or septic shock. Sixty-seven patients (13.1%) were nonsurvivors. Augmented renal clearance was uncommon (5.1% of patients by MDRD and 3.0% by CKD-EPI) and was not associated with increased mortality. Our results are limited by the absence of prospective determination of augmented renal clearance. However, in this small cohort, augmented renal clearance as assessed by MDRD and CKD-EPI does not seem to be a risk factor for mortality in patients with Enterobacteriaceae sepsis. Future studies should assess this finding prospectively.

Abstract Background Multidrug-resistant organism (MDRO) infections are associated with high mortality and readmission rates. Infectious diseases (ID) consultation improves clinical outcomes for drug-resistant Staphylococcus aureus bloodstream infections. Our goal was to determine the association between ID consultation and mortality following various MDRO infections. Methods This study was conducted with a retrospective cohort (January 1, 2006–October 1, 2015) at an academic tertiary referral center. We identified patients with MDROs in a sterile site or bronchoalveolar lavage/bronchial wash culture. Mortality and readmissions within 1 year of index culture were identified, and the association of ID consultation with these outcomes was determined using Cox proportional hazards models with inverse weighting by the propensity score for ID consultation. Results A total of 4214 patients with MDRO infections were identified. ID consultation was significantly associated with reductions in 30-day and 1-year mortality for resistant S. aureus (hazard ratio [HR], 0.48; 95% confidence interval [CI], 0.36–0.63; and HR, 0.73, 95% CI, 0.61–0.86) and Enterobacteriaceae (HR, 0.41; 95% CI, 0.27–0.64; and HR, 0.74; 95% CI, 0.59–0.94), and 30-day mortality for polymicrobial infections (HR, 0.51; 95% CI, 0.31–0.86) but not Acinetobacter or Pseudomonas. For resistant Enterococcus, ID consultation was marginally associated with decreased 30-day mortality (HR, 0.81; 95% CI, 0.62–1.06). ID consultation was associated with reduced 30-day readmission for resistant Enterobacteriaceae. Conclusions ID consultation was associated with significant reductions in 30-day and 1-year mortality for resistant S. aureus and Enterobacteriaceae, and 30-day mortality for polymicrobial infections. There was no association between ID consultation and mortality for patients with resistant Pseudomonas, Acinetobacter, or Enterococcus, possibly due to small sample sizes. Our results suggest that ID consultation may be beneficial for patients with some MDRO infections.

To the Editor—Multidrug-resistant organisms (MDROs) are responsible for an increasing number of infections each year.1 An oft-cited statistic is that MDRO infections cause>2 million illnesses and 23,000 deaths each year in the United States.1 However, the true burden of MDRO infections remains uncertain due to insufficient national reporting rates and an absence of ICD-10 codes specifically for MDRO infections. [...]we sought to provide an updated estimate of deaths due to MDRO infections in the United States. With rampant overuse of antibiotics, establishment of MDRO breeding and transmission centers (long-term acute-care hospitals and nursing facilities), and increasing rates of iatrogenic immunosuppression, the population at risk for MDRO infections and the likelihood of drug resistance will continue to increase. Jason P. Burnham, Division of Infectious Diseases, Washington University School of Medicine, 4523 Clayton Avenue, Campus Box 8051, St Louis, MO 63110.

Studies comparing the impact of the COVID-19 pandemic on diagnostic microbiology culture yields and antimicrobial resistance proportions in low-to-middle-income and high-income countries are lacking. A retrospective study using blood, respiratory, and urine microbiology data from a community hospital in India and two community hospitals (Hospitals A and B) in St. Louis, MO, USA was performed. We compared the proportion of cultures positive for selected multi-drug-resistant organisms (MDROs) listed on the WHO’s priority pathogen list both before the COVID-19 pandemic (January 2017–December 2019) and early in the COVID-19 pandemic (April 2020–October 2020). The proportion of blood cultures contaminated with coagulase-negative Staphylococcus (CONS) was significantly higher during the pandemic in all three hospitals. In the Indian hospital, the proportion of carbapenem-resistant (CR) Klebsiella pneumoniae in respiratory cultures was significantly higher during the pandemic period, as was the proportion of CR Escherichia coli in urine cultures. In the US hospitals, the proportion of methicillin-resistant Staphylococcus aureus in blood cultures was significantly higher during the pandemic period in Hospital A, while no significant increase in the proportion of Gram-negative MDROs was observed. Continuity of antimicrobial stewardship activities and better infection prevention measures are critical to optimize outcomes and minimize the burden of antimicrobial resistance among COVID-19 patients.

Background Telemedicine use is increasing in many specialties, but its impact on clinical outcomes in infectious diseases has not been systematically studied and reviewed. The proposed systematic review will evaluate the current evidence regarding the effect of telemedicine infectious diseases consultation on a range of clinical outcomes, including mortality, hospital readmission, antimicrobial use, and cost. Method/design Standard systematic review methodology will be used, with searches of Ovid MEDLINE 1946-, https://embase.com/ 1947-, Scopus 1823-, Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Register of Controlled Trials (CENTRAL), and https://clinicaltrials.gov/ 1997-. There will be no restriction on language or year of publication. The primary outcome will be 30-day all-cause mortality and secondary outcomes will include readmission within 30 days after discharge from an initial hospitalization with an infection, patient compliance/adherence, patient satisfaction, cost or cost effectiveness, length of hospital stay, antimicrobial use, and antimicrobial stewardship. Bias will be assessed using standard Cochrane methodologies. Data will be grouped by outcome and narratively synthesized. Meta-analysis will be performed for outcomes with clinical or methodological homogeneity. The systematic review and meta-analysis will be registered through PROSPERO. Pre-planned subgroup analyses will be detailed. Discussion A number of studies have documented the feasibility of telemedicine for infectious diseases, but a synthesis of clinical outcomes data with telemedicine infectious diseases consultation has not been performed. This systematic review will analyze many clinical outcomes of telemedicine infectious diseases consultation. The findings of this study will add to established literature about feasibility of telemedicine consultation by synthesizing the evidence for clinical effectiveness. Systematic review registration PROSPERO CRD42018105225

OBJECTIVES/GOALS: The objective of this study is to examine implementation science and clinical outcomes of telemedicine ID consultation at a rural Missouri hospital. METHODS/STUDY POPULATION: Pilot study, hybrid type 2, studying clinical outcomes (mortality, readmission, hospital transfer) and implementation outcomes assessed by survey and chart review (feasibility, acceptability, appropriateness, fidelity to guideline-based care). Telemedicine ID consultations are carried out for patients at Missouri Baptist Sullivan Hospital (MBSH) with positive blood cultures and charts reviewed for 30 days after hospital discharge. Patients, physicians, and staff complete surveys for implementation outcomes. The practical, robust implementation and sustainability model (PRISM) was chosen as the framework for this study and its future scale-up. RESULTS/ANTICIPATED RESULTS: There were 46 patients with positive blood cultures at MBSH, 20 of which were transferred or left from the ER before consultation could be offered. Eighteen patients had telemedicine ID consultation. The remaining 8 patients had contaminants in their blood cultures and therefore no consultation was offered. Of eligible patients not transferred, recruitment rate was 100% (18/18). Average total time per consult was 52.8 minutes on day 1, 8.5 minutes on day 2. 30-day mortality was 0%, 30-day readmission rate 5.5% (n = 1), hospital transfer rate 5.5% (n = 1). 13 patients and 9 providers completed the feasibility, acceptability, and appropriateness survey with zero negative responses on any measure. DISCUSSION/SIGNIFICANCE OF IMPACT: Telemedicine ID consultation at a single rural hospital has thus far been received as feasible, acceptable, and appropriate. Scale-up of this model of care remains to be studied.