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The intent of this document is to highlight practical recommendations in a concise format designed to assist acute-care hospitals in implementing and prioritizing their surgical-site infection (SSI) prevention efforts. This document updates the Strategies to Prevent Surgical Site Infections in Acute Care Hospitals published in 2014.1 This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.

OBJECTIVE To describe pathogen distribution and antimicrobial resistance patterns for healthcare-associated infections (HAIs) reported to the National Healthcare Safety Network (NHSN) from pediatric locations during 2011-2014. METHODS Device-associated infection data were analyzed for central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infections (CAUTI), ventilator-associated pneumonia (VAP), and surgical site infection (SSI). Pooled mean percentage resistance was calculated for a variety of pathogen-antimicrobial resistance pattern combinations and was stratified by location for device-associated infections (neonatal intensive care units [NICUs], pediatric intensive care units [PICUs], pediatric oncology and pediatric wards) and by surgery type for SSIs. RESULTS From 2011 to 2014, 1,003 hospitals reported 20,390 pediatric HAIs and 22,323 associated pathogens to the NHSN. Among all HAIs, the following pathogens accounted for more than 60% of those reported: Staphylococcus aureus (17%), coagulase-negative staphylococci (17%), Escherichia coli (11%), Klebsiella pneumoniae and/or oxytoca (9%), and Enterococcus faecalis (8%). Among device-associated infections, resistance was generally lower in NICUs than in other locations. For several pathogens, resistance was greater in pediatric wards than in PICUs. The proportion of organisms resistant to carbapenems was low overall but reached approximately 20% for Pseudomonas aeruginosa from CLABSIs and CAUTIs in some locations. Among SSIs, antimicrobial resistance patterns were similar across surgical procedure types for most pathogens. CONCLUSION This report is the first pediatric-specific description of antimicrobial resistance data reported to the NHSN. Reporting of pediatric-specific HAIs and antimicrobial resistance data will help identify priority targets for infection control and antimicrobial stewardship activities in facilities that provide care for children. Infect Control Hosp Epidemiol 2018;39:1-11.

Little is known about the molecular epidemiology of Staphylococcus aureus in Chinese neonatal intensive care units (NICUs). We describe the molecular epidemiology of S. aureus isolated from neonates on admission to Beijing Children's Hospital. From May 2015-March 2016, nasal swabs were obtained on admission from 536 neonates. Cultures were also obtained from body sites with suspected infections. S. aureus isolates were characterized by staphylococcal chromosomal cassette (SCCmec) type, staphylococcal protein A (spa) type, multilocus sequence type (MLST), sasX gene, antimicrobial susceptibility and cytotoxicity. Logistic regression assessed risk factors for colonization. Overall, 92 (17%) infants were colonized with S. aureus and 20 (3.7%) were diagnosed with culture-positive S. aureus infection. Of the colonized infants, 70% (64/92) harbored methicillin-susceptible S. aureus (MSSA), 30% (28/92) harbored methicillin-resistant S. aureus (MRSA) while 70% (14/20) of infected infants were culture-positive for MRSA, 30% (6/20) were culture-positive for MSSA. Risk factors for colonization included female sex, age 7-28 days, higher birthweight (3270 IQR [2020-3655] grams) and vaginal delivery (p<0.05). The most common MRSA and MSSA clones were community-associated ST59-SCCmecIVa-t437 (60%) and ST188-t189 (15%), respectively. The sasX gene was not detected. Some MSSA isolates (16%) were penicillin-susceptible and some MRSA isolates (18%) were oxacillin-susceptible. MRSA and MSSA had similar cytotoxicity, but colonizing strains were less cytotoxic than strains associated with infections. S. aureus colonization was common in infants admitted to our NICU and two community-associated clones predominated. Several non-modifiable risk factors for S. aureus colonization were identified. These results suggest that screening infants for S. aureus upon admission and targeting decolonization of high-risk infants and/or those colonized with high-risk clones could be useful to prevent transmission.

Healthcare-associated transmission of nontuberculous mycobacteria (NTM) among people with cystic fibrosis (pwCF) has been reported and is of increasing concern. No standardized epidemiologic investigation tool has been published for healthcare-associated NTM outbreak investigations. This report describes the design of an ongoing observational study to standardize the approach to NTM outbreak investigation among pwCF. This is a parallel multi-site study of pwCF within a single Center who have respiratory NTM isolates identified as being highly-similar. Participants have a history of positive airway cultures for NTM, receive care within a single Center, and have been identified as part of a possible outbreak based on genomic analysis of NTM isolates. Participants are enrolled in the study over a 3-year period. Primary endpoints are identification of a shared healthcare-associated encounter(s) among patients in a Center and identification of environmental isolates that are genetically highly-similar to respiratory isolates recovered from pwCF. Secondary endpoints include characterization of potential transmission modes and settings, as well as incidence and prevalence of healthcare-associated environmental NTM species/subspecies by geographical region. We hypothesize that genetically highly-similar strains of NTM among pwCF cared for at the same Center may arise from healthcare sources including patient-to-patient transmission and/or acquisition from environmental sources. This novel study design will establish a standardized, evidence-based epidemiologic investigation tool for healthcare-associated NTM outbreak investigation within CF Care Centers, will broaden the scope of independent outbreak investigations and demonstrate the frequency and nature of healthcare-associated NTM transmission in CF Care Centers nationwide. Furthermore, it will provide valuable insights into modeling risk factors associated with healthcare-associated NTM transmission and better inform future infection prevention and control guidelines. This study will systematically characterize clinically-relevant NTM isolates of CF healthcare environmental dust and water biofilms and set the stage to describe the most common environmental sources within the healthcare setting harboring clinically-relevant NTM isolates. ClinicalTrials.gov NCT04024423. Date of registry July 18, 2019.

Antimicrobial stewardship programs (ASPs) have been shown to improve antimicrobial prescribing and patient outcomes,1–3 and interest in including a wider range of disciplines in ASPs has grown.4 Because of their bedside responsibilities, acute-care nurses have been identified as potential ASP team members.5 We conducted the first large-scale survey of US nurses at several acute-care hospitals to explore their knowledge, attitudes, and practices in antimicrobial stewardship activities and to identify opportunities for additional nursing involvement in ASPs. Acute-care nurses at a 2,200-bed, 5-campus academic hospital system with active ASPs in New York City were invited to participate in a web-based, anonymous, 31-question survey regarding principles of antimicrobial stewardship (see supplementary material). The survey had a relatively low response rate, and because responses to the survey were voluntary, respondents may not be representative of all nurses at our hospital system.

Infections caused by community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) are being increasingly observed in patients who lack traditional risk factors. We described 8 postpartum women who developed skin and soft-tissue infections caused by MRSA at a mean time of 23 days (range, 4-73 days) after delivery. Infections included 4 cases of mastitis (3 of which progressed to breast abscess), a postoperative wound infection, cellulitis, and pustulosis. The outbreak strains were compared with the prototype CA-MRSA strain MW2 and found to be indistinguishable by pulsed-field gel electrophoresis. All were spa type 131, all contained the staphylococcal chromosomal cassette mec type IV, and all expressed Panton-Valentine leukocidin and staphylococcal enterotoxins C and H. The route of transmission was not discovered: the results of surveillance cultures of samples obtained from employees of the hospital, the hospital environment, and newborns were negative for the outbreak strain. We report that MW2, which was previously limited to the midwestern United States, has spread to the northeastern United States and has become a health care-associated pathogen.

The leading cause of climate change and global warming is the increase in greenhouse gas emissions. 1 The health impacts of climate change and extreme weather events include temperature-associated illnesses and deaths, air pollution-associated chronic respiratory illness, water-and foodborne infections, and vector-borne and zoonotic infections. 2 There is a clear link between climate change and SHEA’s mission-critical concerns, such as healthcare-associated infections, antimicrobial resistance (AMR), and the spread of Candidozyma auris within healthcare settings. 3 Moreover, climate change increases the frequency and severity of bacterial, fungal, and vector-borne diseases including gastroenteritis, skin and soft tissue infections, and respiratory illnesses. 4 Broader infectious disease and public health threats resulting from climate change include the northward spread of Vibrio vulnificus along the Atlantic coastline and a global expansion of mosquito vectors with local transmission of malaria and dengue. 5,6 Therefore, as healthcare epidemiologists, infection preventionists and antibiotic stewards concerned with public health and providing safe healthcare to all, it is incumbent on us to reduce the driving factors of climate change within our domains and mitigate adverse health impacts. Interventions to reduce excess antibiotic days of therapy, including shorter antibiotic courses, earlier de-escalation of broad-spectrum agents or intravenous (IV) to oral (PO) switch, can reduce plastic waste associated with IV administrations and have a positive and direct impact on reducing healthcare-associated carbon emissions. 8 Moreover, measures to improve diagnostic stewardship by avoiding unnecessary diagnostic testing or leveraging reflexive testing have downstream positive impacts on reducing plastic waste and energy consumption while improving patient outcomes. [...]all stewardship programs should implement and scale up proven interventions like de-escalation/cessation, IV to PO switch, and diagnostic stewardship to reduce healthcare utilization and waste and improve patient outcomes. Spivak et al measured greenhouse gas emissions from unnecessary outpatient antibiotic prescriptions. 8 13,580,000 estimated unnecessary prescriptions in the United States approximating 993,906 miles driven in a gas-powered car Hojat et al led a multi-society effort to develop a calculator to compare carbon emissions of various IV or PO antimicrobial regimens.18 Antibiotic Waste Calculator In 2023, the “Sustainabil-ID” interest group of pediatric and adult infectious diseases providers was established to promote sustainability interventions in ID. 18,19 Member Spotlight: Preeti Jaggi and Shreya Doshi—Pediatric Infectious Diseases Society Infection prevention and control Lalakea et al implemented an educational intervention on hand hygiene, appropriate glove use, and environmental impacts to reduce non-sterile glove overuse in surgical specialty outpatient clinics. 11 An average of 4719 gloves saved per month with a total savings of 56,628 gloves, 180.2 kg of waste and $3,003.17 per year, with projected 1472–1767 kg reduction in CO2 emissions, equivalent to 3766–4519 miles driven in a gas-powered car. Pearl et al conducted a SHEA Research Network survey of hospital epidemiologists, IPC directors, and infection preventionists on knowledge, attitudes, and institutional practices related to environmental sustainability and IPC. 20 Most respondents supported or had in place sustainable measures like donation of gently used or unused medical supplies, pursuit of LEED green buildings certification, water/energy conservation, reusable PPE, and “greener” chemicals for low-level disinfection Greene et al developed a conflict-based pragmatic approach to reducing single-use plastics in healthcare, which can be applied to AS, and IPC-based interventions, among others. 21 “No conflict”—immediately implementable “Context-dependent”—requires further exploration “Value conflict”—too high risk/too many safety concerns Note.

Background: Reflexive urine culturing, a strategy wherein urine cultures are only performed on samples with pyuria, is increasingly being used to reduce unnecessary urine cultures, healthcare costs, and inappropriate antibiotics. To support implementation of a reflexive urine-culture order for pediatric patients aged <18 years, we assessed the proportion of urine cultures that would be avoided with reflexive urine culturing, and we calculated the sensitivity and negative predictive value (NPV) of the ≥10 white blood cells (WBC) per high-powered field (HPF) threshold for diagnosing urinary tract infections (UTI) in patients aged <18 years who presented to the pediatric emergency department (ED). Methods: A retrospective review of patients <18 years with a urine culture performed from January to May 2022 in an urban, tertiary-care, pediatric ED was performed. A positive urine culture was defined as ≥50,000 CFU/mL for catheterized specimens and ≥100,000 CFU/mL for clean-catch or unspecified specimens. Pyuria was defined as ≥10 WBC/HPF. ‘True UTI’ was defined as a positive urine culture with a consistent clinical presentation (eg, fever or dysuria). Sensitivity, specificity, and NPV were calculated using the pyuria threshold of ≥10WBC/HPF compared to the gold standard of a ‘true UTI.’ Results: During the study period, 658 patients aged <18 years had urine cultures sent, of which 46 (7%) were positive. In all, 407 urine cultures (61.9%) were obtained by clean catch, 233 (35.4%) were obtained by urethral catheterization, 2 (0.3%) were obtained by Foley catheter, and 16 (2.4%) were unspecified. Among the 46 positive cultures, 32 (69.6%) had ≥10 WBC/HPF, and 55 (9.0%) of 612 negative cultures had ≥10 WBC/HPF. Of the 14 patients with positive urine cultures without pyuria, 8 had a contaminated sample or asymptomatic bacteriuria, 3 had urologic abnormalities, and 3 were infants aged <3 months. Of the 14 patients, 3 (21.4%) had a consistent clinical presentation for UTI and were treated with antibiotics: 2 were infants aged <3 months and 1 had urologic abnormalities. Using the ≥10 WBC/HPF threshold compared to ‘true UTI,’ sensitivity was 91.4%, specificity was 91.5%, positive predictive value was 36%, and NPV was 99.5%. Sensitivity and NPV increased to 100% when infants aged <3 months and urologic patients with positive urine culture were excluded. We estimated a cost saving of ~$200,000 had reflexive testing been in place. Conclusions: A reflexive urine culture for specimens with ≥10 WBC/HPF would have reduced the number of urine cultures substantially because 571 (86.8%) of 658 urine cultures would not have been performed. To prevent missed diagnoses of UTI, infants aged <3 months and children with urologic abnormalities should be excluded from this diagnostic stewardship intervention. Disclosures: None

Background Adherence with tobramycin inhalation solution (TIS) during routine cystic fibrosis (CF) care may differ from recommended guidelines and affect health care utilization. Methods We analyzed 2001-2006 healthcare claims data from 45 large employers. Study subjects had diagnoses of CF and at least 1 prescription for TIS. We measured adherence as the number of TIS therapy cycles completed during the year and categorized overall adherence as: low ≤ 2 cycles, medium >2 to <4 cycles, and high ≥ 4 cycles per year. Interquartile ranges (IQR) were created for health care utilization and logistic regression analysis of hospitalization risk was conducted by TIS adherence categories. Results Among 804 individuals identified with CF and a prescription for TIS, only 7% (n = 54) received ≥ 4 cycles of TIS per year. High adherence with TIS was associated with a decreased risk of hospitalization when compared to individuals receiving ≤ 2 cycles (adjusted odds ratio 0.40; 95% confidence interval 0.19-0.84). High adherence with TIS was also associated with lower outpatient service costs (IQR: $2,159-$8444 vs. $2,410-$14,423) and higher outpatient prescription drug costs (IQR: $35,125-$60,969 vs. $10,353-$46,768). Conclusions Use of TIS did not reflect recommended guidelines and may impact other health care utilization.

Background: Neonatal intensive care units (NICU) outbreaks caused by methicillin-susceptible Staphylococcus aureus (MSSA) are less commonly reported than outbreaks caused by methicillin-resistant S. aureus. We report an unusual outbreak of MSSA skin and soft tissue infections (SSTIs) in a level IV NICU investigated by whole genome sequencing (WGS) and molecular typing. Methods: An investigation was initiated in a 56-single-bed NICU after four patients developed MSSA SSTIs in Week 1. Case-patients had positive MSSA cultures identified by clinical cultures or surveillance sampling (bilateral nares, axillae, umbilicus, and groin), and antibiotic susceptibility testing was performed. WGS and assessment of isolate relatedness through mutation event analysis and multi-locus sequence typing (MLST) was performed by the NYS DOH. Demographic and isolate characteristics were compared using Wilcoxon rank sum test, Fisher’s exact test and Pearson’s Chi-squared test, as appropriate. Results: From Week 2 to Week 32, 9 rounds of surveillance for MSSA colonization were conducted. In all, 30 case-patients had MSSA colonization and 16 infants developed infections including impetigo (n=7), pustules (n=5), staphylococcal scalded skin syndrome (SSSS, n=2), abscess (n=1), and bacteremia (n=1). All SSTI cases presented on infants’ faces, all of whom were on non-invasive respiratory support. MLST identified 4 distinct types including MLST 121 (n=12), MLST 398 (n=10), MLST 30 (n=6), and MLST 15 (n=6). Eight isolates were unrelated to other isolates. MLST 398 and MLST 30 included isolates not closely related (>9 mutation events). The 12 MLST 121 isolates were closely related (≤9 mutational events between all isolates), harbored the mupA gene, and were mupirocin-resistant (MIC>1024 ug/ml). Clinical infection and mupirocin resistance were associated with MLST 121 (Table 1). Multiple infection control measures were implemented, including increased availability of alcohol-based hand sanitizers, introducing bare-below-the-elbows practice for staff, contact precautions for case-patients, decolonization with mupirocin and chlorhexidine baths, environmental cleaning/disinfection, and removing excess equipment and supplies. No new cases of mupirocin-resistant or MLST 121 SSTIs occurred after Week 25. Conclusion: We report a MSSA outbreak associated with multiple MLST types and a predominant mupirocin-resistant strain. This report highlights the ability of molecular typing to characterize strains causing infections versus colonization and the potential loss of mupirocin as a control measure when outbreaks are caused by mupirocin-resistant strains. WGS analysis allows for increased discrimination of mutation events allowing for improved resolution of case relatedness compared to other typing methods. Successful control of this outbreak was achieved with a multitude of infection prevention and control.