Estimated hospital costs associated with preventable health care-associated infections if health care antiseptic products were unavailable

Detecting diseases in medical prescriptions using data mining methods

Every year, the health of millions of people around the world is compromised by misdiagnosis, which sometimes could even lead to death. In addition, it entails huge financial costs for patients, insurance companies, and governments. Furthermore, many physicians' professional life is adversely affected by unintended errors in prescribing medication or misdiagnosing a disease. Our aim in this paper is to use data mining methods to find knowledge in a dataset of medical prescriptions that can be effective in improving the diagnostic process. In this study, using 4 single classification algorithms including decision tree, random forest, simple Bayes, and K-nearest neighbors, the disease and its category were predicted. Then, in order to improve the performance of these algorithms, we used an Ensemble Learning methodology to present our proposed model. In the final step, a number of experiments were performed to compare the performance of different data mining techniques. The final model proposed in this study has an accuracy and kappa score of 62.86% and 0.620 for disease prediction and 74.39% and 0.720 for prediction of the disease category, respectively, which has better performance than other studies in this field.In general, the results of this study can be used to help maintain the health of patients, and prevent the wastage of the financial resources of patients, insurance companies, and governments. In addition, it can aid physicians and help their careers by providing timely information on diagnostic errors. Finally, these results can be used as a basis for future research in this field.

A stratification strategy to predict secondary infection in critical illness-induced immune dysfunction: the REALIST score

BACKGROUND

Although multiple individual immune parameters have been demonstrated to predict the occurrence of secondary infection after critical illness, significant questions remain with regards to the selection, timing and clinical utility of such immune monitoring tests.

RESEARCH QUESTION

As a sub-study of the REALISM study, the REALIST score was developed as a pragmatic approach to help clinicians better identify and stratify patients at high risk for secondary infection, using a simple set of relatively available and technically robust biomarkers.

STUDY DESIGN AND METHODS

This is a sub-study of a single-centre prospective cohort study of immune profiling in critically ill adults admitted after severe trauma, major surgery or sepsis/septic shock. For the REALIST score, five immune parameters were pre-emptively selected based on their clinical applicability and technical robustness. Predictive power of different parameters and combinations of parameters was assessed. The main outcome of interest was the occurrence of secondary infection within 30 days.

RESULTS

After excluding statistically redundant and poorly predictive parameters, three parameters remained in the REALIST score: mHLA-DR, percentage of immature (CD10^- CD16^-) neutrophils and serum IL-10 level. In the cohort of interest (n = 189), incidence of secondary infection at day 30 increased from 8% for patients with REALIST score of 0 to 46% in patients with a score of 3 abnormal parameters, measured ad D5-7. When adjusted for a priori identified clinical risk factors for secondary infection (SOFA score and invasive mechanical ventilation at D5-7), a higher REALIST score was independently associated with increased risk of secondary infection (42 events (22.2%), adjusted HR 3.22 (1.09-9.50), p = 0.034) and mortality (10 events (5.3%), p = 0.001).

INTERPRETATION

We derived and presented the REALIST score, a simple and pragmatic stratification strategy which provides clinicians with a clear assessment of the immune status of their patients. This new tool could help optimize care of these individuals and could contribute in designing future trials of immune stimulation strategies.

Antimicrobial performance of two preoperative skin preparation solutions containing iodine and isopropyl alcohol

BACKGROUND

Healthcare-associated infections (HAIs) are a persistent clinical challenge caused primarily by bacteria on the skin. Proper utilization of optimized antiseptic skin preparation solutions helps reduce the prevalence and impact of HAIs by decreasing patient skin microorganisms preoperatively. The purpose of this study was to evaluate the efficacy of 2 antimicrobial solutions containing iodine and isopropyl alcohol (IPA): Povidone iodine (PVP-I) with IPA (ie, PVP-I+IPA, PurPrep) and Iodine Povacrylex+IPA (DuraPrep).

METHODS

The antimicrobial activity of the test solutions was evaluated in vitro by determinations of minimum inhibitory concentrations (MICs) and minimum bactericidal concentrations (MBCs) against 1105 diverse microbial isolates and a time-kill assay to evaluate efficacy against 120 strains of Gram-positive and Gram-negative bacteria and yeasts. Peel tests were performed between skin samples treated with test solutions and representative drape/dressing materials to determine effects of test solutions on the biomechanical adhesion properties. Finally, an Institutional Review Board (IRB)-approved, randomized, controlled, single-center, partially blinded in vivo study was performed to assess the immediate and persistent antimicrobial activity of the test solutions on the abdomen and groin.

RESULTS

Both PVP-I+IPA and Iodine Povacrylex+IPA solutions demonstrated broad-spectrum antimicrobial activity with MIC and MBC at less than 1% of the full-strength concentration of each product against a wide variety of microorganisms. In the time-kill tests, both solutions were able to successfully reduce all microbial populations by 99.99% (ie, 4 log₁₀) at the contact times of 30 seconds, 2 minutes and 10 minutes. The 2 solutions showed relatively similar adhesion results when tested with 3 representative operating room materials. Both PVP-I+IPA and Iodine Povacrylex+IPA met the expected Food and Drug Administration (FDA) efficacy requirements at 10 minutes and 6 hours post-treatment for both anatomic sites (ie, groin, and abdomen) in the clinical study, with no safety issues or adverse events.

CONCLUSIONS

Analysis of the in vitro antimicrobial activity, biomechanical adhesive strength, and in vivo efficacy of PVP-I+IPA demonstrated similar results compared to Iodine Povacrylex+IPA. Both products were efficacious at reducing or eliminating a wide range of clinically-relevant microorganisms in lab-based and clinical settings, supporting their use as antiseptic skin preparation solutions to reduce bacteria on the skin that can cause infection.

An Overview of Healthcare Associated Infections and Their Detection Methods Caused by Pathogen Bacteria in Romania and Europe

Healthcare-associated infections can occur in different care units and can affect both patients and healthcare professionals. Bacteria represent the most common cause of nosocomial infections and, due to the excessive and irrational use of antibiotics, resistant organisms have appeared. The most important healthcare-associated infections are central line-associated bloodstream infections, catheter-associated urinary tract infections, surgical site, soft tissue infections, ventilator-associated pneumonia, hospital acquired pneumonia, and Clostridioides difficile colitis. In Europe, some hospitalized patients develop nosocomial infections that lead to increased costs and prolonged hospitalizations. Healthcare-associated infection prevalence in developed countries is lower than in low-income and middle-income countries such as Romania, an Eastern European country, where several factors contribute to the occurrence of many nosocomial infections, but official data show a low reporting rate. For the rapid identification of bacteria that can cause these infections, fast, sensitive, and specific methods are needed, and they should be cost-effective. Therefore, this review focuses on the current situation regarding healthcare-associated infections in Europe and Romania, with discussions regarding the causes and possible solutions. As a possible weapon in the fight against the healthcare-associated infections, the diagnosis methods and tests used to determine the bacteria involved in healthcare-associated infections are evaluated.

Rigidity-Activity Relationships of bisQPC Scaffolds Against Pathogenic Bacteria

Biscationic quaternary phosphonium compounds (bisQPCs) represent a promising class of antimicrobials, displaying potent activity against both Gram-negative and Gram-positive bacteria. In this study, we explored the effects of structural rigidity on the antimicrobial activity of QPC structures bearing a two-carbon linker between phosphonium groups, testing against a panel of six bacteria, including multiple strains harboring known disinfectant resistance mechanisms. Using simple alkylation reactions, 21 novel compounds were prepared, although alkene isomerization as well as an alkyne reduction were observed during the respective syntheses. The resulting bisQPC compounds showed strong biological activity, but were hampered by diminished solubility of their iodide salts. One compound (P2P-10,10 I) showed single digit micromolar activity against the entire panel of bacteria. Overall, intriguing biological activity was observed, with more rigid structures displaying better efficacy against Gram-negative strains and less rigid structures demonstrating slightly increased efficacy against S. aureus strains.

Microbial contamination on ambulance surfaces: A systematic literature review

BACKGROUND

Healthcare-associated infections (HAIs) are infections that patients acquire while receiving medical treatment in a healthcare facility. During ambulatory transport, the patient may be exposed to pathogens transmitted from emergency medical service (EMS) personnel or EMS surfaces.

AIM

To determine whether organisms commonly associated with HAIs have been detected on surfaces in the patient care compartment of ambulances.

METHODS

Five electronic databases - PubMed, Scopus, Web of Science, Embase, and Google Scholar were used to search for articles using inclusion and exclusion criteria following the PRISMA checklist. Inclusion criteria consisted of articles published in English, between 2009 - 2020, had positive samples collected from the patient care compartment of a ground ambulance, and reported sample collection methods of either swab sampling and/or Replicate Organism Detection and Counting (RODAC) contact plates. Studies not meeting these criteria were excluded from this review.

FINDINGS

From a total of 1,376 articles identified, 16 were included in the review. Organisms associated with HAIs were commonly detected in the patient care compartment of ambulances across a variety of different surfaces, including blood pressure cuffs, oxygen apparatuses, and areas of patient stretchers.

CONCLUSION

A high prevalence of pathogenic bacteria in ambulances suggest that standard protocols related to cleaning compliance may not be effective. The primary recommendation is that designated subject matter experts in infection prevention should be incorporated as liaisons in the pre-hospital setting, acting as a link between the pre-hospital (e.g., ambulance transport) and hospital environments.

Incidence rate and financial burden of medical errors and policy interventions to address them: a multi-method study protocol

Medical error is one of the most critical challenges facing medical services. They pose a substantial threat to patient safety, and their costs draw attention from policymakers, health care planners and researchers. We aim to make a realistic estimation of medical error incidence and related costs and identify factors influencing this incidence in Iranian hospitals. In the first phase of this multi-method study, through two reviews of systematic reviews and a meta-analysis, we will estimate the incidence of medical errors and the strategies to reduce them. We will extract available data among 41 hospitals supervised by the East Azerbaijan University in the second phase. We will also develop a model and use a Delphi method to predict medical errors incidence and calibrate our model output using the Monte Carlo simulation. We will compare this estimation with the incidence rate based on meta-analysis results from the first phase. In the third phase, we will investigate the relationship between several factors potentially influencing medical error incidence. In the fourth phase, we will estimate costs associated with medical errors by conducting a patient records review and matching those with claims related to medical errors. In the fifth phase, we will present a policy brief related to strategies for medical errors and associated costs reduction in Iran. Our findings could benefit Iranian and policymakers in other countries to reduce medical errors and associated costs.

Association and risk factors of healthcare-associated infection and burden of illness among chemotherapy-induced ulcerative mucositis patients

Objectives

To evaluate the association and risk factors of healthcare-associated infection (HAI) and burden of illness among chemotherapy-induced ulcerative mucositis (UM) patients.

Methods

For this research, US National Inpatient Sample database 2017 was utilized to study UM patients. The association of healthcare-associated infection-related burden of illness among UM patients was assessed on the outcome––length of hospital stays (LOS), total charges, in-hospital mortality, and discharge disposition.

Result

In 2017, there were 11,350 adult (> 18 years of age) UM patients, among them there were 415 (3.5%) HAI. After adjusting for patient and clinical characteristics, UM patients with HAI were most likely to have higher total charges and longer LOS (1.91; 95% CIs: 1.51–2.41; P < 0.001; 1.84; 95% CIs: 1.53–2.21; P < 0.001) than those without HAI. Further, mortality was not significantly different. UM patients with HAI were less likely to have higher burden of illness who were younger, females, those living in non-metropolitan or micropolitan counties, and those with lower co-morbidity score. Additionally, UM patients with HAI were more likely to discharge to skilled nursing facility (SNF), intermediate care facility (ICF), and another type of facility (ATF), (aOR = 2.58 (1.16–5.76), P = 0.02), than they were to discharge to self-care or home care.

Conclusion

UM patients with HAI were more likely to have higher burden of illness and more likely to discharged to the SNF, ICF, and ATF rather than to home or self-care.

Clinical relevance

UM patients when associated with HAI have higher burden of illness; a tailored approach to oral care might prevent HAIs and burden of illness among UM.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00784-021-04106-0.

Cost savings associated with nutritional support in medical inpatients: an economic model based on data from a systematic review of randomised trials

BACKGROUND AND AIMS

Nutritional support improves clinical outcomes during hospitalisation as well as after discharge. Recently, a systematic review of 27 randomised, controlled trials showed that nutritional support was associated with lower rates of hospital readmissions and improved survival. In the present economic modelling study, we sought to determine whether in-hospital nutritional support would also return economic benefits.

METHODS

The current economic model applied cost estimates to the outcome results from our recent systematic review of hospitalised patients. In the underlying meta-analysis, a total of 27 trials (n=6803 patients) were included. To calculate the economic impact of nutritional support, a Markov model was developed using transitions between relevant health states. Costs were estimated accounting for length of stay in a general hospital ward, hospital-acquired infections, readmissions and nutritional support. Six-month mortality was also considered. The estimated daily per-patient cost for in-hospital nutrition was US$6.23.

RESULTS

Overall costs of care within the model timeframe of 6 months averaged US$63 227 per patient in the intervention group versus US$66 045 in the control group, which corresponds to per patient cost savings of US$2818. These cost savings were mainly due to reduced infection rate and shorter lengths of stay. We also calculated the costs to prevent a hospital-acquired infection and a non-elective readmission, that is, US$820 and US$733, respectively. The incremental cost per life-day gained was -US$1149 with 2.53 additional days. The sensitivity analyses for cost per quality-adjusted life day provided support for the original findings.

CONCLUSIONS

For medical inpatients who are malnourished or at nutritional risk, our findings showed that in-hospital nutritional support is a cost-effective way to reduce risk for readmissions, lower the frequency of hospital-associated infections, and improve survival rates.

Timing of Preoperative Surgical Antibiotic Prophylaxis After Primary One-Level to Three-Level Lumbar Fusion

OBJECTIVE

The purpose of this study was to examine the relationship between timing of preoperative surgical antibiotic prophylaxis and postoperative surgical site infections (SSIs) among patients with 1-level to 3-level lumbar fusion.

METHODS

Patients having undergone a primary 1-level to 3-level lumbar fusion at a single institution were allocated into 5 groups based on the time from preoperative antibiotic administration to incision (group A, 0-15 minutes; group B, 16-30 minutes; group C, 31-45 minutes; group D, 46-60 minutes; and group E, 61+ minutes). Timing of antibiotic administration as a continuous variable was also analyzed. All patients received irrigation with 3 L of normal saline containing bacitracin as well as local administration of vancomycin powder. SSIs were identified by the definition set forth by the 2017 Centers for Disease Control and Prevention guidelines.

RESULTS

Among 1131 patients, 27 (2.4%) were found to have an SSI. Compared with patients with antibiotic administration within 0-15 minutes before incision, patients with administration 61+ minutes before incision (group 4) had significantly higher odds of developing an SSI (P < 0.001). Patients had a 1.05-fold higher likelihood of infection for each additional minute delay of administration before incision (P < 0.001). Receiver operating characteristic analysis reported an area under the curve of 0.733 and 0.776 for time as a continuous and categorical variable, respectively. Age (P = 0.02), body mass index (P = 0.03), diabetes mellitus diagnosis (P = 0.04), and type of antibiotic (P = 0.004) were significant predictors of SSI.

CONCLUSIONS

Our results show that preoperative antibiotic administration beyond 1 hour in patients who have undergone lumbar fusion is associated with higher rates of SSI.

A customizable deep learning model for nosocomial risk prediction from critical care notes with indirect supervision

OBJECTIVE

Reliable longitudinal risk prediction for hospitalized patients is needed to provide quality care. Our goal is to develop a generalizable model capable of leveraging clinical notes to predict healthcare-associated diseases 24-96 hours in advance.

METHODS

We developed a reCurrent Additive Network for Temporal RIsk Prediction (CANTRIP) to predict the risk of hospital acquired (occurring ≥ 48 hours after admission) acute kidney injury, pressure injury, or anemia ≥ 24 hours before it is implicated by the patient's chart, labs, or notes. We rely on the MIMIC III critical care database and extract distinct positive and negative cohorts for each disease. We retrospectively determine the date-of-event using structured and unstructured criteria and use it as a form of indirect supervision to train and evaluate CANTRIP to predict disease risk using clinical notes.

RESULTS

Our experiments indicate that CANTRIP, operating on text alone, obtains 74%-87% area under the curve and 77%-85% Specificity. Baseline shallow models showed lower performance on all metrics, while bidirectional long short-term memory obtained the highest Sensitivity at the cost of significantly lower Specificity and Precision.

DISCUSSION

Proper model architecture allows clinical text to be successfully harnessed to predict nosocomial disease, outperforming shallow models and obtaining similar performance to disease-specific models reported in the literature.

CONCLUSION

Clinical text on its own can provide a competitive alternative to traditional structured features (eg, lab values, vital signs). CANTRIP is able to generalize across nosocomial diseases without disease-specific feature extraction and is available at https://github.com/h4ste/cantrip.

The critical role of infection prevention overlooked in Ethiopia, only one-half of health-care workers had safe practice: A systematic review and meta-analysis

BACKGROUND

Effective infection prevention and control measures, such as proper hand hygiene, the use of personal protective equipment, instrument processing, and safe injection practicein the healthcare facilitiesare essential elements of patient safety and lead to optimal patient outcomes. In Ethiopia, findings regarding infection prevention practices among healthcare workers have been highly variable and uncertain. This systematic review and meta-analysis estimates the pooled prevalence of safe infection prevention practices and summarizesthe associated factors among healthcare workers in Ethiopia.

METHODS

PubMed, Science Direct, Google Scholar, and the Cochran library were systematically searched. We included all observational studies reporting the prevalence of safe infection prevention practices among healthcare workers in Ethiopia. Two authors independently extracted all necessary data using a standardized data extraction format. Qualitative and quantitative analyseswere employed. The Cochran Q test statistics and I2 tests were used to assess the heterogeneity of the studies. A random-effects meta-analysis model was used to estimate the pooled prevalence of safe infection prevention practice.

RESULTS

Of the 187 articles identified through our search, 10 studies fulfilled the inclusion criteria and were included in the meta-analysis. The pooled prevalence of safe infection prevention practice in Ethiopia was 52.2% (95%CI: 40.9-63.4). The highest prevalence of safe practice was observed in Addis Ababa (capital city) 66.2% (95%CI: 60.6-71.8), followed by Amhara region 54.6% (95%CI: 51.1-58.1), and then Oromia region 48.5% (95%CI: 24.2-72.8), and the least safe practices were reported from South Nation Nationalities and People (SNNP) and Tigray regions with a pooled prevalence of 39.4% (95%CI: 13.9-64.8). In our qualitative syntheses, the odds of safe infection prevention practice were higher among healthcare workers who had good knowledge and a positive attitude towards infection prevention. Also, healthcare workers working in facilities with continuous running water supply, having infection prevention guideline, and those received training were significantly associated withhigher odds of safe infection prevention practice.

CONCLUSIONS

Infection prevention practices in Ethiopia was poor, with only half of the healthcare workers reporting safe practices. Further, the study found out that there were regional and professional variations in the prevalence of safe infection prevention practices. Therefore, the need to step-up efforts to intensify the current national infection prevention and patient safety initiative as key policy direction is strongly recommended, along with more attempts to increase healthcare worker's adherence towards infection prevention guidelines.

Healthcare-associated infections among patients hospitalized for cancers of the lip, oral cavity and pharynx

Introduction

The negative consequences of healthcare-associated infections (HAI) on the burden of illness (BOI) of cancer patients are well-established. However, there is a paucity of research on HAI among cancers of the lip, oral cavity and pharynx (CLOCP), and whether HAI-related BOI differed for other common solid tumors–malignant neoplasm of the colon (MNC) and malignant neoplasm of the lung (MNL).

Methods

We utilized the United States' National Inpatient Sample database 2017 to study longitudinal inpatient hospital stay of CLOCP, MNC and MNL. Patient demographics and hospital characteristics of patients were assessed, and the impact of HAI-related BOI compared based on differences in length of hospital stays (LOS), total charges during hospitalization and mortality were compared.

Findings

In 2017, of the 54,934 patients with CLOCP, 1.2% had HAI, compared to MNC (n=64,470) with 2% HAI and MNL (n=154,685) with 1.2% HAI. In adjusted multivariable regression analysis, we determined CLOCP patients with HAI had LOS of 5.6 days longer (95% CIs, 3.0–8.2 days, P < 0.001), and hospitalization charges of $40,341 higher (95%CIs 15,715–64,967, P < 0.01) than the non-HAI CLOCP patients. Mortality was not significantly different among HAI and non-HAI CLOCP patients (odds ratio: 0.80; 95%CIs 0.35–1.87, P = 0.6). In unadjusted analysis, LOS and total charges were higher for CLOCP-HAI patients vs. MNC-HAI or MNL-HAI patients.

Conclusion

HAI in patients with CLOCP patients were associated with an increased BOI, and this is considerably higher than observed in patients with MNC or MNL patients who had HAI.

Novel Detection of Nasty Bugs, Prevention Is Better than Cure

Hospital-acquired infections (HAIs) are a growing concern around the world. They contribute to increasing mortality and morbidity rates and are an economic threat. All hospital patients have the potential to contract an HAI, but those with weakened or inferior immune systems are at highest risk. Most hospital patients will contract at least one HAI, but many will contract multiple ones. Bacteria are the most common cause of HAIs and contribute to 80-90% of all HAIs, with Staphylococcus aureus, Clostridium difficile, Escherichia coli, Acinetobacter baumannii, Pseudomonas aeruginosa and Klebsiella pneumoniae accounting for the majority. Each of these bacteria are highly resistant to antibiotics and can produce a protective film, known as a biofilm, to further prevent their eradication. It has been shown that by detecting and eradicating bacteria in the environment, infection rates can be reduced. The current methods for detecting bacteria are time consuming, non-specific, and prone to false negatives or false positives. Aptamer-based biosensors have demonstrated specific, time-efficient and simple detection, highlighting the likelihood that they could be used in a similar way to detect HAI-causing bacteria.

Perspectives and practices of healthcare providers and caregivers on healthcare-associated infections in the neonatal intensive care units of two hospitals in Ghana

Healthcare-associated infections (HAIs) remain a serious threat to patient safety worldwide, particularly in low- and middle-income countries. Reducing the burden of HAIs through the observation and enforcement of infection prevention and control (IPC) practices remains a priority. Despite growing emphasis on HAI prevention in low- and middle-income countries, limited evidence is available to improve IPC practices to reduce HAIs. This study examined the perspectives of healthcare providers (HPs) and mothers in the neonatal intensive care unit on HAIs and determined the major barriers and facilitators to promoting standard IPC practices. This study draws on data from an ethnographic study using 38 in-depth interviews, four focus group discussions and participant observation conducted among HPs and mothers in neonatal intensive care units of a secondary- and tertiary-level hospital in Ghana. The qualitative data were analysed using a grounded theory approach, and NVivo 12 to facilitate coding. HPs and mothers demonstrated a modest level of understanding about HAIs. Personal, interpersonal, community, organizational and policy-level factors interacted in complex ways to influence IPC practices. HPs sometimes considered HAI concerns to be secondary in the face of a heavy clinical workload, a lack of structured systems and the quest to protect professional authority. The positive attitudes of some HPs, and peer interactions promoted standard IPC practices. Mothers expressed interest in participation in IPC activities. It however requires systematic efforts by HPs to partner with mothers in IPC. Training and capacity building of HPs, provision of adequate resources and improving communication between HPs and mothers were recommended to improve standard IPC practices. We conclude that there is a need for institutionalizing IPC policies and strengthening strategies that acknowledge and value mothers' roles as caregivers and partners in IPC. To ensure this, HPs should be better equipped to prioritize communication and collaboration with mothers to reduce the burden of HAIs.

Antibiotic resistance and sensitivity pattern of Metallo-β-Lactamase Producing Gram-Negative Bacilli in ventilator-associated pneumonia in the intensive care unit of a public medical school hospital in Bangladesh

BACKGROUND

Ventilator-associated pneumonia (VAP) is the most common nosocomial infection in intensive care units (ICU), accounting for 25% of all ICU infections. Antimicrobial resistance is increasing and becoming a significant health problem worldwide, increasing hospital length of stay, mortality and costs. Identifying antibiotic resistance patterns in VAP is important as this can cause outbreaks in ICUs. To date, there have been limited studies assessing this in Bangladesh. Consequently, the primary objective of this research was to study the species of bacterial growth and to determine the antibiotic resistance patterns of Metallo-β-Lactamase (MBL) producing gram-negative bacilli among ICU patients with VAP in a public medical school hospital, Bangladesh. In addition, identify the factors associated with a positive culture to provide future guidance.

METHOD

Cross-sectional study performed in the Chattogram Medical College Hospital, Bangladesh. Mueller Hinton agar plates were used for antibiotic sensitivity testing by the Kirby-Buer disc diffusion test.

RESULTS

Among 105 clinically suspected VAP cases, qualitative cultures were positive in 95 (90%) of them. The most common bacteria identified were Acinetobacter spp. (43.2%), Klebsiella spp. (20%) and Pseudomonas spp. (18.9%). A positive culture was not associated with patients' age or gender. Among 41 isolated Acinetobacter spp., 38 (92.7%) were resistant to gentamicin followed by 36 (87.8%) to ceftriaxone. Among 24 isolated Klebsiella spp., 22 (83.3%) were resistant to ceftriaxone. Among 18 isolated Pseudomonas spp., 16 (88.8%) were resistant to ciprofloxacin, and 13 (72.2%) were resistant to ceftriaxone. Among nine isolated E. coli, all were resistant to ceftriaxone and ciprofloxacin. All four Proteus spp. (100%) isolated were resistant to ciprofloxacin. Additionally, phenotype MBL producing was 65.22% and genotype was 45.65% among imipenem resistant pathogens. Imipenem resistant pathogens were sensitive to amoxyclav, amikacin¸ azithromycin, ceftazidime, ceftriaxone, colistin and gentamycin.

CONCLUSION

A positive culture was detected in 90% of VAP patients, but it was not associated with the patients' age and gender. The most common bacteria identified were Acinetobacter spp., Klebsiella spp. and Pseudomonas spp., where the majority of these were resistant to ceftriaxone. The results are being used to provide future guidance on the empiric management of VAP in this hospital.

Reduction of Health Care-Associated Infections (HAIs) with Antimicrobial Inorganic Nanoparticles Incorporated in Medical Textiles: An Economic Assessment

Health care-associated infections (HAIs) affect millions of patients annually with up to 80,000 affected in Europe on any given day. This represents a significant societal and economic burden. Staff training, hand hygiene, patient identification and isolation and controlled antibiotic use are some of the standard ways to reduce HAI incidence but this is time consuming and subject and subject to rigorous implementation. In addition, the lack of antimicrobial activity of some disinfectants against healthcare-associated pathogens may also affect the efficacy of disinfection practices. Textiles are an attractive substrate for pathogens because of contact with the human body with the attendant warmth and moisture. Textiles and surfaces coated with engineered nanomaterials (ENMs) have shown considerable promise in reducing the microbial burden on those surfaces. Studies have also shown that this antimicrobial affect can reduce the incidence of HAIs. For all of the promising research, there has been an absence of study on the economic effectiveness of ENM coated materials in a healthcare setting. This article examines the relative economic efficacy of ENM coated materials against an antiseptic approach. The goal is to establish the economic efficacy of the widespread usage of ENM coated materials in a healthcare setting. In the absence of detailed and segregated costs, benefits and control variables over at least cross sectional data or time series, an aggregated approach is warranted. This approach, while relying on some supposition allows for a comparison with similar data regarding standard treatment to reduce HAIs and provides a reasonable economic comparison. We find that while, relative to antiseptics, ENM coated textiles represent a significant clinical advantage, they can also offer considerable cost savings.

Deep Learning from Incomplete Data: Detecting Imminent Risk of Hospital-acquired Pneumonia in ICU Patients

Hospital acquired pneumonia (HAP) is the second most common nosocomial infection in the ICU and costs an estimated $3.1 billion annually. The ability to predict HAP could improve patient outcomes and reduce costs. Traditional pneumonia risk prediction models rely on a small number of hand-chosen signs and symptoms and have been shown to poorly discriminate between low and high risk individuals. Consequently, we wanted to investigate whether modern data-driven techniques applied to respective pneumonia cohorts could provide more robust and discriminative prognostication of pneumonia risk. In this paper we present a deep learning system for predicting imminent pneumonia risk one or more days into the future using clinical observations documented in ICU notes for an at-risk population (n = 1, 467). We show how the system can be trained without direct supervision or feature engineering from sparse, noisy, and limited data to predict future pneumonia risk with 96% Sensitivity, 72% AUC, and 80% F1-measure, outperforming SVM approaches using the same features by 20% Accuracy (relative; 12% absolute).

Length of Stay Predicts Risk of Early Infection for Hospitalized Patients Undergoing Central Venous Port Placement

PURPOSE

To compare early totally implantable central venous port catheter-related infection rates after inpatient vs outpatient placement and to determine whether the risk associated with inpatient placement is influenced by length of hospital stay.

MATERIALS AND METHODS

In this single-institution retrospective study, 5,301 patients (3,618 women; mean age 57 y) underwent port placement by interventional radiologists between October 2004 and January 2018. The 30-day infection rate was compared between inpatients and outpatients using survival analysis. Among inpatients, the effect of time from admission to port placement and from placement to discharge was analyzed using a survival regression tree.

RESULTS

The 30-day infection rate was 3.6% (95% confidence interval [CI] = 1.9%-6.1%) among 386 inpatients and 1.0% (95% CI = 0.7%-1.3%) among 4,915 outpatients (hazard ratio [HR] = 3.6, 95% CI = 2.0-6.6, P < .001). Inpatient placement was a significant risk factor after accounting for covariates in multivariate analysis (HR = 2.2, 95% CI = 1.0-4.7, P = .05) and controlling for demographic differences by propensity score matching (HR = 2.8, 95% CI = 1.0-7.8, P = .04). Infection rate was 11% (95% CI = 4.7%-22%) among 65 inpatients in whom time from admission to placement was ≥ 7 days, 5.1% (95% CI = 1.9%-11%) among 129 inpatients in whom admission to placement was < 7 days and time to discharge was > 3 days, and 0% (95% CI = 0%-2.1%) among 192 inpatients in whom admission to placement was < 7 days and time to discharge was ≤ 3 days (P < .001).

CONCLUSIONS

Inpatient port placement was associated with a higher risk of early infection. However, a clinical decision tree based on shorter length of stay before and after placement may identify a subset of hospitalized patients not at increased risk for infection.

Safety Evaluation of Individual Pillboxes to Control Cross-Contamination in the Drug Circuit in Hospitals

This study aims to evaluate the potential role of pillboxes used for the preparation and delivery of individual daily medical treatments in the drug circuit of the Military Instruction Hospital (France) as reservoirs of bacterial contaminants. Samples were obtained from 32 pillboxes after decontamination (T1), after preparation in the pharmacy (T2), after use in two different medical units (T3), and again after usual mechanical washing (T4). Qualitative (identification and antibiotic susceptibility) and quantitative (contamination rate and number of colony forming units-CFUs) bacteriological tests were performed. Susceptible and resistant strains of environmental saprophytes were identified. The pillbox contamination rate was relatively low at T1 (13%). It was significantly increased at T2 (63%, p = 0.001 vs. T1), again at T3 (88%, p < 0.05 vs. T2, p < 0.001 vs. T1), and finally decreased dramatically at T4 (31%, p < 0.001 vs. T3, p > 0.05 vs. T1). The number of CFUs was significantly increased at T2 compared with that of T1 (36.7 ± 13.4 and 5.36 ± 3.64, respectively, p < 0.001) and again at T3 (84.4 ± 19.4, p < 0.001 vs. T1 and T2) and was significantly reduced at T4 (7.0 ± 2.0 vs. T3, p < 0.001) to a level that was not significantly different from that at T1. So, the use of pillboxes to deliver individual medications to patients in the hospital is a potential risk factor for bacterial cross-contamination.

Optimizing a Whole-Genome Sequencing Data Processing Pipeline for Precision Surveillance of Health Care-Associated Infections

The surveillance of health care-associated infection (HAI) is an essential element of the infection control program. While whole-genome sequencing (WGS) has widely been adopted for genomic surveillance, its data processing remains to be improved. Here, we propose a three-level data processing pipeline for the precision genomic surveillance of microorganisms without prior knowledge: species identification, multi-locus sequence typing (MLST), and sub-MLST clustering. The former two are closely connected to what have widely been used in current clinical microbiology laboratories, whereas the latter one provides significantly improved resolution and accuracy in genomic surveillance. Comparing to a broadly used reference-dependent alignment/mapping method and an annotation-dependent pan-/core-genome analysis, we implemented our reference- and annotation-independent, k-mer-based, simplified workflow to a collection of Acinetobacter and Enterococcus clinical isolates for tests. By taking both single nucleotide variants and genomic structural changes into account, the optimized k-mer-based pipeline demonstrated a global view of bacterial population structure in a rapid manner and discriminated the relatedness between bacterial isolates in more detail and precision. The newly developed WGS data processing pipeline would facilitate WGS application to the precision genomic surveillance of HAI. In addition, the results from such a WGS-based analysis would be useful for the precision laboratory diagnosis of infectious microorganisms.

Using social media to disseminate research in infection prevention, hospital epidemiology, and antimicrobial stewardship

Social media, prevention of healthcare-associated infections (HAIs) and antimicrobial stewardship (ASP) each impact every area of medicine. Independently, each have power to change medicine, however, synergistically, the impact could be transformative. Given the profound clinical, financial, and public health impact of infection prevention and antimicrobial stewardship combined with the incomplete uptake of best practices, multimodal strategies employing social media are critical to increase the speed and reach of research. This review discusses the strategic utilization of online communication platforms to increase the dissemination of critical publications.

Healthcare-associated infections including neonatal bloodstream infections in a leading tertiary hospital in Botswana

Background: Healthcare-associated infections (HAIs) increase morbidity, mortality, length of hospital stay and costs, and should be prevented where possible. In addition, up to 71% of neonates are prone to bloodstream infections (BSI) during intensive care due to a variety of factors. Consequently, the objectives of this study were to estimate the burden of HAIs and possible risk factors in a tertiary hospital in Botswana as well as describe current trends in bacterial isolates from neonatal blood specimen and their antibiotic resistance patterns.Methods: Point Prevalence Survey (PPS) in all hospital wards and a retrospective cross-sectional review of neonatal blood culture and sensitivity test results, with data abstracted from the hospital laboratory database.Results: 13.54% (n = 47) of patients had HAIs, with 48.9% (n = 23) of them lab-confirmed. The highest prevalence of HAIs was in the adult intensive care unit (100% - n = 5), the nephrology unit (50% - n = 4), and the neonatal intensive care unit (41.9% - n = 13). One-fourth of HAIs were site unspecific, 19.1% (n = 9) had surgical site infections (SSIs), 17% (n = 8) ventilator-associated pneumonia/complications, and 10.6% (n = 5) were decubitus ulcer infections. There were concerns with overcrowding in some wards and the lack of aseptic practices and hygiene. These issues are now being addressed through a number of initiatives. Coagulase Negative Staphylococci (CoNS) was the commonest organism (31.97%) isolated followed by Enterococci spp. (18.03%) among neonates. Prescribing of third-generation cephalosporins is being monitored to reduce Enterococci, Pseudomonas and Acinetobacter spp. infections.Conclusions: There were concerns with the rate of HAIs and BSIs. A number of initiatives are now in place in the hospital to reduce these including promoting improved infection prevention and control (IPC) practices and use of antibiotics via focal persons of the multidisciplinary IPC committee. These will be followed up and reported on.

The Mutation of Conservative Asp268 Residue in the Peptidoglycan-Associated Domain of the OmpA Protein Affects Multiple Acinetobacter baumannii Virulence Characteristics

Acinetobacter baumannii is a nosocomial human pathogen of increasing concern due to its multidrug resistance profile. The outer membrane protein A (OmpA) is an abundant bacterial cell surface component involved in A. baumannii pathogenesis. It has been shown that the C-terminal domain of OmpA is located in the periplasm and non-covalently associates with the peptidoglycan layer via two conserved amino acids, thereby anchoring OmpA to the cell wall. Here, we investigated the role of one of the respective residues, D268 in OmpA of A. baumannii clinical strain Ab₁₆₉, on its virulence characteristics by complementing the ΔompA mutant with the plasmid-borne ompA_D268A allele. We show that while restoring the impaired biofilm formation of the ΔompA strain, the Ab₁₆₉ompA_D268A mutant tended to form bacterial filaments, indicating the abnormalities in cell division. Moreover, the Ab₁₆₉ OmpA D268-mediated association to peptidoglycan was required for the manifestation of twitching motility, desiccation resistance, serum-induced killing, adhesion to epithelial cells and virulence in a nematode infection model, although it was dispensable for the uptake of β-lactam antibiotics by outer membrane vesicles. Overall, the results of this study demonstrate that the OmpA C-terminal domain-mediated association to peptidoglycan is critical for a number of virulent properties displayed by A. baumannii outside and within the host.

Increased Healthcare-Associated Infections in a Surgical Intensive Care Unit Related to Boarding Non-Surgical Patients

Background: Hospital over-capacity often forces boarding patients outside of their designated intensive care unit (ICU). Anecdotal evidence suggested medical intensive care unit (MICU) patients boarding in the surgical intensive care unit (SICU) were responsible for increases in healthcare-associated infection (HAI) rates. We studied the effect of ICU boarding on rates of SICU HAIs. Methods: This single-center, retrospective two-year database study compared primary SICU patients (Home) to MICU patients boarding in the SICU (Boarders). Variables studied included age, gender, Acute Physiology and Chronic Health Evaluation III (APACHE III) scores, and comorbidities. Healthcare-associated infections included Clostridium difficile infection, catheter-associated urinary tract infections, central line-associated blood stream infection, and ventilator-associated pneumonia. Student t-test, Fisher exact testing, and a multivariable regression model were used to determine the significance of associations. Results: A total of 2,562 patients were included in the study; 328 (12.8%) were Boarders and 2,234 (87.2%) were Home. Univariable analysis demonstrated that Boarders were older (64.0 ± 16.9 vs. 60.2 ± 17.4), more severely ill (APACHE III score 70.5 ± 31.1 vs. 53.4 ± 21.9), more likely to have cirrhosis, coronary artery disease, and asthma/chronic obstructive pulmonary disease, but less likely to have hypertension. On univariable analysis boarding was associated with an increase HAI rate (19 HAI/1,000 patient days vs. 6.2, p < 0.001). Multivariable regression modeling demonstrated boarding status remained independently associated with HAI (odds ratio [OR] 1.83 95% confidence interval [CI] 1.02-3.27). Cost estimates demonstrated an additional cost of $83,303 per 1,000 patient days. Conclusion: The practice of hospital boarding is associated with development of HAI and increased hospital costs. Efforts at determining the cause of this increase and then reducing HAIs will improve patient care and help hospital budgets.

Sepsis and Nosocomial Infection: Patient Characteristics, Mechanisms, and Modulation

Sepsis is a leading cause of death worldwide. After initial trials modulating the hyperinflammatory phase of sepsis failed, generations of researchers have focused on evaluating hypo-inflammatory immune phenotypes. The main goal has been to develop prognostic biomarkers and therapies to reduce organ dysfunction, nosocomial infection, and death. The depressed host defense in sepsis has been characterized by broad cellular reprogramming including lymphocyte exhaustion, apoptosis, and depressed cytokine responses. Despite major advances in this field, our understanding of the dynamics of the septic host response and the balance of inflammatory and anti-inflammatory cellular programs remains limited. This review aims to summarize the epidemiology of nosocomial infections and characteristic immune responses associated with sepsis, as well as immunostimulatory therapies currently under clinical investigation.

Effectiveness of national and subnational infection prevention and control interventions in high-income and upper-middle-income countries: a systematic review

Evidence-based guidance for national infection prevention and control (IPC) programmes is needed to support national and global capacity building to reduce health-care-associated infection and antimicrobial resistance. In this systematic review we investigate evidence on the effectiveness of IPC interventions implemented at national or subnational levels to inform the development of WHO guidelines on the core components of national IPC programmes. We searched CENTRAL, CINAHL, Embase, MEDLINE, and WHO IRIS databases for publications between Jan 1, 2000, and April 19, 2017. 29 studies that met the eligibility criteria (ie, economic evaluations, cluster-randomised trials, non-randomised trials, controlled before-and-after studies, and interrupted time-series studies exploring the effective of these interventions) were categorised according to intervention type: multimodal, care bundles, policies, and surveillance, monitoring, and feedback. Evidence of effectiveness was found in all categories but the best quality evidence was on multimodal interventions and surveillance, monitoring, and feedback. We call for improvements in study design, reporting of research, and quality of evidence particularly from low-income countries, to strengthen the uptake and international relevance of IPC interventions.