Explore the vast range of titles available.

Nursing home (NH) residents in the United States routinely attend interactive visits for services such as therapy or dialysis, creating opportunities for pathogen transmission. A paucity of studies exist which delineate spread of pathogens beyond residents’ in-room environment. In this prospective cohort study, we recruited 197 newly-admitted residents across three Veterans Affairs NHs to characterize multidrug-resistant organism (MDRO) prevalence, acquisition, and transmission. Participant hands, nares, groin, and seven environmental surfaces were swabbed during 758 regularly scheduled in-room visits; participant hands, healthcare personnel hands, and equipment were swabbed during 345 unscheduled interactive visits. We demonstrate that baseline MDRO colonization and new acquisition is common, and one in six interactive visits result in MDRO transmission. Whole genome sequencing on a subset of participants enabled us to identify sources of transmission where it was unknown using microbiologic methods alone. Our results illustrate MDRO transmission pathways and highlight the need for innovative, multidisciplinary interventions. Nursing homes are high-risk settings for transmission of infections, but risks associated with specific activities are not well understood. Here, the authors investigate transmission dynamics of multi-resistant organisms in nursing homes in the United States with a focus on out-of-room, interactive visits.

The molecular genetic mechanisms of sex determination are not known for most vertebrates, including zebrafish. We identified a mutation in the zebrafish fancl gene that causes homozygous mutants to develop as fertile males due to female-to-male sex reversal. Fancl is a member of the Fanconi Anemia/BRCA DNA repair pathway. Experiments showed that zebrafish fancl was expressed in developing germ cells in bipotential gonads at the critical time of sexual fate determination. Caspase-3 immunoassays revealed increased germ cell apoptosis in fancl mutants that compromised oocyte survival. In the absence of oocytes surviving through meiosis, somatic cells of mutant gonads did not maintain expression of the ovary gene cyp19a1a and did not down-regulate expression of the early testis gene amh; consequently, gonads masculinized and became testes. Remarkably, results showed that the introduction of a tp53 (p53) mutation into fancl mutants rescued the sex-reversal phenotype by reducing germ cell apoptosis and, thus, allowed fancl mutants to become fertile females. Our results show that Fancl function is not essential for spermatogonia and oogonia to become sperm or mature oocytes, but instead suggest that Fancl function is involved in the survival of developing oocytes through meiosis. This work reveals that Tp53-mediated germ cell apoptosis induces sex reversal after the mutation of a DNA-repair pathway gene by compromising the survival of oocytes and suggests the existence of an oocyte-derived signal that biases gonad fate towards the female developmental pathway and thereby controls zebrafish sex determination.

Background: In rural areas, antimicrobial stewardship programs often have limited access to infectious disease (ID) expertise. Videoconference Antimicrobial Stewardship Teams (VASTs) pair rural Veterans Affairs (VA) medical centers with an ID expert to discuss treatment of patients with concerns for infection. In a pilot study, VASTs were effective at improving antimicrobial use. Here, we evaluated 12-month operating costs for staffing for 3 VASTs. Methods: We used the following data to describe 12 months of clinical encounters for 3 VASTs operating from January 2022 – March 2023: the number of VAST sessions completed and clinical encounters; Current Procedural Terminology (CPT) codes associated with clinical encounters; session attendees (by role) and the time spent (percent effort) on VAST-related activities. The annual operating cost was based on the annual salaries and percent effort of VAST attendees. We used these characteristics combined with private-sector and Medicare reimbursements to evaluate the cost of implementation and number of clinical encounters needed to offset those costs (breakeven) for each site. Results: Three VASTs recorded 229 clinical encounters during 117 sessions (Table 1). Based on CPT codes, the approximate revenue per patient was $516.46. Site A, the only site to break even, had the most sessions and clinical encounters as well as the lowest operating costs. For Site B, a slight increase in the clinical encounters, which might be achieved by 3 additional VAST sessions, would help achieve breakeven. For Site C, increasing the number of clinical encounters to 3-4 per session would have helped their VAST break even without requiring a decrease in operating costs. Conclusions: The frequency of VAST sessions, volume of clinical encounters, and low operating costs all contributed the VAST at Site A achieving a financial break-even point within 12 months. Consideration of the potential number of clinical encounters and sessions will help other VASTs achieve financial sustainment, independent of cost-savings related to potential decreases in expenditures for antibiotics and antibiotic-related adverse events. These results also provide insight into possible adoption and diffusion of VAST-like programs in the Medicare hospital setting.

Background: Healthcare settings without access to infectious diseases experts may struggle to implement effective antibiotic stewardship programs. We previously described a successful pilot project using the Veterans Affairs (VA) telehealth system to form a Videoconference Antimicrobial Stewardship Team (VAST) that connected multidisciplinary teams from rural VA medical centers (VAMCs) with infectious diseases experts at geographically distant locations. VASTs discussed patients from the rural VAMC, with the overarching goal of supporting antibiotic stewardship. This project is currently ongoing. Here, we describe preliminary outcomes describing the cases discussed, recommendations made, and acceptance of those recommendations among 4 VASTs. Methods: Cases discussed at any of the 4 participating intervention sites were independently reviewed by study staff, noting the infectious disease diagnoses, recommendations made by infectious diseases experts and, when applicable, acceptance of those recommendations at the rural VAMC within 1 week. Discrepancies between independent reviewers were discussed and, when consensus could not be reached, discrepancies were discussed with an infectious diseases clinician. Results: The VASTs serving 4 different rural VAMCs discussed 96 cases involving 92 patients. Overall, infection of the respiratory tract was the most common syndrome discussed by VASTs (Fig. 1). The most common specific diagnoses among discussed cases were cellulitis (n = 11), acute cystitis (n = 11), wounds (n = 11), and osteomyelitis (n = 10). Of 172 recommendations, 41 (24%) related to diagnostic imaging or laboratory results and 38 (22%) were to change the antibiotic agent, dose, or duration (Fig. 2). Of the 151 recommendations that could be assessed via chart review, 122 (81%) were accepted within 1 week. Conclusions: These findings indicate successful implementation of telehealth to connect clinicians at rural VAMCs with an offsite infectious diseases expert. The cases represented an array of common infectious syndromes. The most frequent recommendations pertained to getting additional diagnostic information and to adjusting, but not stopping, antibiotic therapy. These results suggest that many of the cases discussed warrant antibiotics and that VASTs may use the results of diagnostic studies to tailor that therapy. The high rate of acceptance suggests that the VASTs are affecting patient care. Future work will describe VAST implementation at 4 additional VAMCs, and we will assess whether using telehealth to disseminate infectious diseases expertise to rural VAMCs supports changes in antibiotic use that align with principles of antimicrobial stewardship. Disclosures: None

Background: Veterans Health Administration (VHA) community living centers (CLCs) provide postacute and long-term care. CLC veterans visit myriad locations outside their rooms (eg, rehabilitation, dialysis). Pathogen transmission during out-of-room visits is unknown. Methods: We recruited newly admitted veterans at 3 CLCs. After obtaining informed consent, we cultured nares, groin, hands, and 7 surfaces in the patient rooms. We accompanied veterans to up to 5 out-of-room visits and cultured patients’ hands and surfaces they touched. We tested for multidrug-resistant organisms (MDROs) including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), and quinolone, carbapenem, and/or ceftazidime-resistant gram-negative bacteria (R-GNB). We defined transmission as a positive culture following an initial negative culture during the same visit. Results: We enrolled 137 veterans (median follow-up, 29 days; mean, 5.9 visits); 97% were postacute patients. We conducted 539 patient-room sampling visits (mean, 3.9 per veteran; 5,490 swabs) and accompanied 97 veterans to 266 out-of-room sampling visits (mean, 2.7 per veteran; 2,360 swabs). Of 137 patients, 47 (35%) were colonized with an MDRO at enrollment and 74 (58%) of 128 patients were colonized on any follow-up patient-room visits. Of 133 patients, 55 (41%) acquired a new MDRO, most often VRE (31 of 97, 32%). In patient rooms, toilet seats [114 (21%) of 538], curtains [101 (19%) of 530] and bedrails [98 (18%) of 539] were most frequently contaminated. Among 266 out-of-room visits, 17% had surfaces contaminated with MDROs, most commonly involving dialysis [4 (31%) of 13], radiology [2 (25%) of 8], and rehabilitation therapy [29 (18%) of 159] (Fig. 1).Transmission of MDROs during out-of-room visits was common and occurred in 18% of visits with 8% (9 MRSA and 12 VRE) acquiring a new MDRO on their hands and 12% (9 MRSA and 23 VRE) of MDRO transmission occurring from hands to a surface that the patient touched (Fig. 1). In 18 (58%) of 31 cases, the organism transmitted to a surface was on patient hands at the start of the visit. Transmission was most common during visits to dialysis (3 to patients and 2 to surfaces), radiology (1 to a patient and 2 to surfaces), and rehabilitation therapy (13 to patients and 21 to surfaces) (Fig. 2). Conclusions: New MDRO acquisition during VHA CLC stay was common, and nearly one-fifth of out-of-room visits resulted in MDRO transmission. Our analyses suggest that veterans’ hands may shed MDROs (MRSA and VRE) to surfaces. Interventions to reduce MDRO transmission during visits for rehabilitation, dialysis, and other therapies are needed. Disclosures: None

Background Predicting which patients will develop severe COVID-19 complications could improve clinical care. Peripheral blood cytokine profiles may predict the severity of SARS-CoV-2 infection, but none have been identified in US Veterans. Methods We analyzed peripheral blood cytokine profiles from 202 participants in the EPIC 3 study, a prospective observational cohort of US Veterans tested for SARS-CoV-2 across 15 VA medical centers. Illness severity was assessed based on the highest level documented during the first 60 days after recruitment. We correlated cytokine levels with illness severity using LASSO logistic regression, random forest, and XGBoost models on a 70% training set and calculated the AUC on a 30% test set. Results LASSO regression identified 6 cytokines as predictors of SARS-CoV-2 severity with 77.3% AUC in the test set. Random forest and XGBoost models achieved an AUC of 80.4% and 80.7% in the test set, respectively. All models assigned a feature importance to each cytokine, with IP-10, MCP-1, and HGF consistently identified as key markers. Conclusions Cytokine profiles are predictive of SARS-CoV-2 severity in US Veterans and may guide tailored interventions for improved patient management.

Abstract Background Telehealth can facilitate improving antibiotic use and related antimicrobial stewardship activities in facilities underserved by infectious diseases (IDs) expertise. We describe implementation of the Department of Veterans Affairs (VA) videoconference antimicrobial stewardship team (VAST) to connect multidisciplinary teams from rural VA medical centers (VAMCs) with geographically distant ID experts. Methods We implemented VASTs at 10 rural VAMCs from September 2021 to February 2024. VASTs consisted of regular meetings between rural VAMCs and an off-site ID expert who met by videoconference to discuss clinical cases, emphasizing recommendations for antibiotic prescribing. The VA Corporate Data Warehouse was used to collect information on patient medical encounter information. Interviews with healthcare professionals and surveys assessed perceptions of and experiences with VASTs. Results VASTs completed 624 clinical encounters on 531 unique patients. Half (53%) of the encounters required >20 minutes. The most frequently discussed infections were respiratory tract (35%), skin and soft tissue (19%), and genitourinary (17%). Of the 73 (53% of 138 contacted) professionals who responded to the survey, >90% perceived VASTs as improving the quality of veteran care and agreed that recommendations were timely. All 24 interviewees identified VASTs as meeting an important need at the rural site and that the virtual system facilitated collaboration. Conclusions These findings indicate successful implementation of a telehealth program to disseminate ID and antimicrobial stewardship expertise to rural VAMCs. This is a strong model augmenting antimicrobial stewardship in other healthcare systems. The videoconference antimicrobial stewardship team (VAST) disseminated infectious disease and antimicrobial stewardship expertise to settings with limited access to infectious disease experts. VAST is scalable and can be disseminated to other healthcare systems and settings.