Incorporating microbial cell-free DNA testing into healthcare-associated invasive fungal infection surveillance: benefits and challengesThis link opens in a new windowSurveillance by clinical epidemiology teams for invasive fungal infections (IFIs) in healthcare settings can be challenging due to several factors including low sensitivity of noninvasive conventional microbiologic diagnostics, nonspecific clinical presentation, and complex patient populations. Recently, availability of microbial cell-free DNA testing (cfDNA) via the Karius Test has shown promise for increased diagnostic sensitivity of IFIs. However, how to best incorporate cfDNA results into IFI surveillance remains a vexing challenge. Herein, we provide perspectives on the benefits and challenges of use of cfDNA for IFI surveillance.Apr 3, 2025
WHO global research agenda for hand hygiene improvement in health care: a Delphi consensus studyThis link opens in a new windowObjective:To identify global research priorities for improving hand hygiene in healthcare settings and develop a 2023–2030 research agenda to guide funding, coordinate research, promote investment, and inform policy for enhanced healthcare quality and safety.Design:Expert consensus study using a modified Delphi process.Participants:A 105-member panel of international hand hygiene experts including the World Health Organization (WHO) Technical Advisory Group of Experts on Hand Hygiene in Healthcare representing all WHO regions and World Bank income levels.Methods:The research priorities were identified through a multiphase approach including a meta-review to establish knowledge gaps and inform initial priorities, followed by expert consultations using a modified Delphi process. 192 preliminary priorities were included in a two-round Delphi survey. Experts rated each priority in the first round, and then reviewed and adjusted responses based on the panel’s aggregated, anonymous responses in the second round. Ratings were collected on a five-point Likert scale. Consensus was defined as a combined “strongly agree” and “agree” frequency of at least 70%.Results:Consensus was achieved for 178 of 192 priorities (92.7%), categorized into six domains: system change; training and education; evaluation and feedback; reminders and communications; institutional safety climate; and hand hygiene improvement impact on healthcare-associated infections and antimicrobial resistance. Of these, 121 priorities reached >80% consensus. The Delphi process, maintained a 92% response rate over two rounds.Conclusions:A structured consensus process yielded a research agenda to address gaps in hand hygiene improvement, supporting enhanced healthcare quality and safety globally.Mar 19, 2025
Improving central line-associated bloodstream infection prevention practices in oncology clinic patients: mobile-app based surveillance & responseThis link opens in a new windowObjectives:To evaluate the impact of a mobile-app-based central line-associated bloodstream infection (CLABSI) prevention program in oncology clinic patients with peripherally inserted central catheters (PICCs).Design:Pre-post prospective cohort study with baseline (July 2015–December 2016), phase-in (January 2017–April 2017), and intervention (May 2017–November 2018). Generalized linear mixed models compared intervention with baseline frequency of localized inflammation/infection and dressing peeling. Cox proportional hazards models compared days-to-removal of lines with localized inflammation/infection. Chi-square test compared bacteremia rates before and after intervention.Setting:Oncology clinic at a large medical center.Patients:Oncology clinic adult patients with PICCs.Intervention:CLABSI prevention program consisting of an actionable scoring system for identifying insertion site infection/inflammation coupled with a mobile-app enabling photo-assessments and automated physician alerting for remote response.Results:We completed 5,343 assessments of 569 PICCs in 401 patients (baseline: 2,924 assessments, 300 PICCs, 216 patients; intervention: 2,419 assessments, 269 PICCs, 185 patients). The intervention was associated with a 92% lower likelihood of having a dressing with peeling (OR 0.08, 95%CI 0.04-0.17, P < 0.001), 53% lower local inflammation/infection (OR 0.47, 95%CI 0.27-0.84, P < 0.011), and 24% (non-significant) lower CLABSI rates (P = .63). Physician mobile-app alerting and response enabled 80% lower risk of lines remaining in place after inflammation/infection was identified (HR 0.20, 95%CI:0.14-0.30, P < 0.001) and 85% faster removal of infected lines from mean (SD) 11.1 (9.7) to 1.7 (2.4) days.Conclusions:A mobile-app-based CLABSI prevention program decreased frequency of inflamed/infected central line insertion sites and increased speed of removal when inflammation/infection was found.Apr 9, 2025
Automated surveillance of hospital-onset bacteremia and fungemia: feasibility and epidemiological results from a Dutch multicenter studyThis link opens in a new windowObjective:Hospital-onset bacteremia and fungemia (HOB) has been suggested as a suitable and automatable surveillance target to include in surveillance programs, however differences in definitions across studies limit interpretation and large-scale implementation. We aimed to apply an automated surveillance system for HOB in multiple hospitals using a consensus definition, and describe HOB rates.Design and setting:Retrospective cohort study in four Dutch hospitals: 1 tertiary hospital and 3 secondary hospitals.Patients:All patients admitted for at least one overnight stay between 2017 and 2021 were included, except patients in psychiatry wards.Methods:Data from the electronic health records and laboratory information system were used to identify HOBs based on the PRAISE consensus definition. HOB rates were calculated at ward and micro-organism-level.Results:Hospital-wide HOB rates varied from 1.0 to 1.9, and ICU rates varied from of 8.2 to 12.5 episodes per 1000 patient days. The median time between admission and HOB was 8–13 days. HOBs were predominantly caused by Enterobacterales, Enterococci, S. aureus and coagulase-negative staphylococci. Longitudinal HOB surveillance detected differences over time at ward and micro-organism level; for example increased HOB rates were observed during the COVID-19 pandemic. Sensitivity analyses demonstrated the impact of assumptions regarding the collection of confirmatory blood cultures for common commensals.Conclusions:Applying a fully automated definition for HOB surveillance was feasible in multiple centers with different data infrastructures, and enabled detection of differences over time at ward and micro-organism-level. HOB surveillance may lead to prevention initiatives in the future.Feb 25, 2025
Risk factor evaluation and performance improvement for surgical site infections in patients undergoing abdominal hysterectomy at a large academic safety net hospitalThis link opens in a new windowObjective:To identify Surgical Site Infection (SSI) risk factors for abdominal hysterectomy patients and report the results of a performance improvement initiative.Design:Retrospective case-control.Setting:Parkland Hospital, an 882-bed academic, safety-net, tertiary referral center and a level 1 trauma center serving a diverse population of primarily uninsured patients in North Texas.Participants:Patients over 18 who underwent abdominal hysterectomy and were diagnosed with SSIs within 30 days of surgery between 2019 and 2021.Methods:Cases were matched to controls from the same or closest calendar month in a 1:2 ratio. Chart review of electronic medical records (EMR) was performed comparing variables using Pearson’s χ2 test for categorical variables and Student’s t-test for continuous variables followed by logistic regression for multivariate analysis. Upon identifying vaginal preparation technique as an area of improvement while investigating SSI bundle compliance, we implemented an OR staff training intervention.Results:Diabetes was identified as a significant risk factor while Hispanic or Latino ethnicity was associated with significantly lower rates of infection. Most organisms identified were enteric pathogens. Following the intervention, Parkland’s deep and organ-space Standardized Infection Ratio (SIR) decreased from 1.46 in 2021 to 0.519 for the rolling 12 months as of June 2024.Conclusions:Our multidisciplinary intervention improving the quality and consistency of pre-operative vaginal preparation was associated with a reduction in abdominal hysterectomy SSI.Apr 6, 2025
Comparison of Medicare claims-based Clostridioides difficile infection epidemiologic case classification algorithms to medical record review by the Emerging Infections Program using a linked cohort, 2016–2021This link opens in a new windowBackground:Medicare claims are frequently used to study Clostridioides difficile infection (CDI) epidemiology. However, they lack specimen collection and diagnosis dates to assign location of onset. Algorithms to classify CDI onset location using claims data have been published, but the degree of misclassification is unknown.Methods:We linked patients with laboratory-confirmed CDI reported to four Emerging Infections Program (EIP) sites from 2016–2021 to Medicare beneficiaries with fee-for-service Part A/B coverage. We calculated sensitivity of ICD-10-CM codes in claims within ±28 days of EIP specimen collection. CDI was categorized as hospital, long-term care facility, or community-onset using three different Medicare claims-based algorithms based on claim type, ICD-10-CM code position, duration of hospitalization, and ICD-10-CM diagnosis code presence-on-admission indicators. We assessed concordance of EIP case classifications, based on chart review and specimen collection date, with claims case classifications using Cohen’s kappa statistic.Results:Of 12,671 CDI cases eligible for linkage, 9,032 (71%) were linked to a single, unique Medicare beneficiary. Compared to EIP, sensitivity of CDI ICD-10-CM codes was 81%; codes were more likely to be present for hospitalized patients (93.0%) than those who were not (56.2%). Concordance between EIP and Medicare claims algorithms ranged from 68% to 75%, depending on the algorithm used (κ = 0.56–0.66).Conclusion:ICD-10-CM codes in Medicare claims data had high sensitivity compared to laboratory-confirmed CDI reported to EIP. Claims-based epidemiologic classification algorithms had moderate concordance with EIP classification of onset location. Misclassification of CDI onset location using Medicare algorithms may bias findings of claims-based CDI studies.Mar 25, 2025
A mixed-methods study assessing the performance of a clinical decision support tool for Clostridioides difficile testing for patients receiving laxativesThis link opens in a new windowObjective:To better understand clinicians’ rationale for ordering testing for C. difficile infection (CDI) for patients receiving laxatives and the impact of the implementation of a clinical decision support (CDS) intervention.Design:A mixed-methods, case series was performed from March 2, 2017 to December 31, 2018.Setting:Yale New Haven Hospital, a 1,541 bed tertiary academic medical center.Participants:Hospitalized patients ≥ 18 years old, and clinicians who were alerted by the CDS.Intervention:CDS was triggered in real-time when a clinician sought to order testing for CDI for a patient who received one or more doses of laxatives within the preceding 24 hours.Results:A total of 3,376 CDS alerts were triggered during the 21-month study period from 2,567 unique clinician interactions. Clinicians bypassed the CDS alert 74.5% of the time, more frequent among residents (48.3% bypass vs. 39.9% accept) and advanced practice providers (APPs) (34.9% bypass vs. 30.6% accept) than attendings (11.3% bypass vs. 22.5% accept). Ordering clinicians noted increased stool frequency/output (48%), current antibiotic exposure (34%), and instructions by an attending physician to test (28%) were among the most common reasons for overriding the alert and proceeding with testing for CDI.Conclusions:Testing for CDI despite patient laxative use was associated with an increased clinician concern for CDI, patient risk for CDI, and attending physician instruction for testing. Attendings frequently accepted CDS guidance while residents and APPs often reinstated CDI test orders, suggesting a need for greater empowerment and discretion when ordering tests.Mar 12, 2025
Real-world clinical impact of plasma cell-free DNA metagenomic next-generation sequencing assayThis link opens in a new windowObjective:To describe the real-world clinical impact of a commercially available plasma cell-free DNA metagenomic next-generation sequencing assay, the Karius test (KT).Methods:We retrospectively evaluated the clinical impact of KT by clinical panel adjudication. Descriptive statistics were used to study associations of diagnostic indications, host characteristics, and KT-generated microbiologic patterns with the clinical impact of KT. Multivariable logistic regression modeling was used to further characterize predictors of higher positive clinical impact.Results:We evaluated 1000 unique clinical cases of KT from 941 patients between January 1, 2017–August 31, 2023. The cohort included adult (70%) and pediatric (30%) patients. The overall clinical impact of KT was positive in 16%, negative in 2%, and no clinical impact in 82% of the cases. Among adult patients, multivariable logistic regression modeling showed that culture-negative endocarditis (OR 2.3; 95% CI, 1.11–4.53; P .022) and concern for fastidious/zoonotic/vector-borne pathogens (OR 2.1; 95% CI, 1.11–3.76; P .019) were associated with positive clinical impact of KT. Host immunocompromised status was not reliably associated with a positive clinical impact of KT (OR 1.03; 95% CI, 0.83–1.29; P .7806). No significant predictors of KT clinical impact were found in pediatric patients. Microbiologic result pattern was also a significant predictor of impact.Conclusions:Our study highlights that despite the positive clinical impact of KT in select situations, most testing results had no clinical impact. We also confirm diagnostic indications where KT may have the highest yield, thereby generating tools for diagnostic stewardship.Jan 29, 2025
Does PCR-based pathogen identification reduce mortality in bloodstream infections? Insights from a difference-in-difference analysisThis link opens in a new windowBackground:Bloodstream infections (BSI) are associated with high mortality rates, particularly when caused by resistant pathogens. Reducing the delay in diagnosis and initiation of appropriate treatment is crucial for improving clinical outcomes. The implementation of polymerase chain reaction (PCR) tests in the diagnostic process offers a promising approach to achieving quicker identification of pathogens, thereby potentially reducing mortality associated with BSI.Methods:A difference-in-differences analysis was performed within a New York City hospital system, comparing mortality risk between patients with enterococcal BSI before and after the adoption of BCID2 PCR testing, using as control those with methicillin-sensitive S. aureus BSI, for which diagnostic protocol has been unchanged.Results:The study included 548 inpatients; 164 diagnosed with vancomycin-resistant enterococci (VRE) BSI and 384 with MSSA BSI. The mean 30-day mortality risk difference in the period post-intervention estimated in our difference-in-differences model was -6.03 per 100 (95% CI: -10.35 to -1.7), with event study plots suggesting minimal deviation from parallel trends in the pre-treatment period.Conclusions:Findings suggest that introduction of BCID2 PCR testing for enterococcal bloodstream infections (BSI) may be associated with a reduction in mortality, however, interpretation of the effects must be approached with caution given the relative imprecision of estimates. Further research with larger samples is essential to establish a definitive conclusion on the impact of rapid PCR testing on mortality in BSI. This is an innovative approach using causal methods to evaluate interventions aimed at the improvement of infection control and antimicrobial treatment strategies.Feb 13, 2025
Real-word utility of procalcitonin in patients hospitalized with community-acquired pneumonia: A matched cohort studyThis link opens in a new windowObjective:To retrospectively observe procalcitonin (PCT) and antibiotic ordering practices in patients hospitalized with community-acquired pneumonia (CAP).Design:Retrospective, exact matched, multicenter cohort study from October 1, 2018 – March 31, 2023.Setting:All hospitals across the Mayo Clinic Enterprise.Participants:Adult patients with CAP, identified using pneumonia diagnosis codes and receipt of systemic antibiotics with an indication of “respiratory tract infection” within 48 hours of hospitalization.Methods:PCT testing within the first 7 days of hospitalization was compared to non-PCT care (nPCT). The primary outcomes were treatment duration, antibiotic days of therapy (DOT), and length of stay (LOS).Results:15364 patients met inclusion criteria. PCT testing occurred in 42.4% (6515/15364) of encounters, totaling 8214 PCT results. 12880 unique patient encounters were matched 1:1, 6440 in each group. Treatment duration was longer in the PCT group compared to the nPCT group (5.1 vs 4.6 days, respectively, P < 0.001). Patients in the PCT group also received more DOT (8.6 vs 7.6 DOT, P < 0.001) and had a longer LOS (6.8 vs 5.9 days, P < 0.001), respectively. There was no difference in 30-day all-cause mortality or C. difficile infection between groups. In a sensitivity analysis of nPCT patients compared to those with a peak value <0.25 ng/mL (i.e. normal result) there was no difference in treatment duration (4.6 days nPCT vs 4.7 days normal PCT, P = 0.104) or LOS (5.9 days nPCT vs 6.0 days normal PCT, P = 0.134).Conclusion:PCT testing in patients hospitalized with CAP was not associated with reduced antimicrobial utilization, LOS, or 30-day all-cause mortality.Feb 27, 2025
Evaluation of Department of Defense hospital antimicrobial stewardship programs (ASPs) using a novel Core Elements scoring approach and modeling Core Elements scores with metrics related to ASP outcomesThis link opens in a new windowObjective:Evaluate Department of Defense (DoD) antimicrobial stewardship programs (ASPs) by assessing the relationship between key clinical outcome metrics (antibiotic use, incidence of resistant pathogens, and incidence of Clostridioides difficile infections) and CDC Core Element (CE) adherence.Design:Retrospective, cross-sectional study of DoD hospitals in 2018 and 2021Methods:National Healthcare Safety Network Standardized Antimicrobial Administration Ratios (SAARs) were used to measure antibiotic use and microbiology results to evaluate four types of pathogen incidence. A novel CE scoring approach used scores to quantitatively assess relationships with CE adherence and outcome metrics using correlation and regression models. Assessments were repeated with 2021 data for Priority CE adherence and to conduct adjusted regressions for CEs and Priority CEs controlling for categorical bed size.Results:Compared to 2022 national data, DoD hospitals in 2021 had a similar proportion of facilities with a SAAR statistically significantly > 1.0. Leadership, Action, and Tracking CEs followed a more normal score distribution, while Reporting and Education were somewhat left-skewed. Unadjusted models often showed a positive relationship with higher CE scores associated with worse outcomes for the SAAR and pathogen incidence. Adjusted models indicated that procedural CEs, particularly Priority Reporting, were associated with better ASP-related outcomes.Conclusions:CEs should be more quantitatively assessed. Results provide initial evidence to prioritize procedural CE implementation within the DoD; however, additional investigation for structural CEs is needed. Patient outcome data should be collected as an important indicator of ASP performance.Mar 12, 2025
