Challenges and success stories of the implementation of infection control and antimicrobial stewardship strategies: proceedings of the 5th Global Ministerial Summit on Patient Safety, 2023

The 5th edition of the Global Ministerial Summit on Patient Safety was held in Montreux, Switzerland, in February 2023, delayed by three years due to the COVID-19 pandemic. The overarching theme of the summit was "Less Harm, Better Care - from Resolution to Implementation", focusing on the challenges of implementation of infection prevention and control (IPC) strategies as well as antimicrobial stewardship programs (ASP) around the world. IPC strategies and ASP are of increasing importance due to the substantial burden of healthcare-associated infections and antimicrobial resistance threatening patient safety. Here, we summarize countries' and regional experiences and activities related to the implementation of IPC strategies and ASP shared at the meeting. Full implementation of effective programs remains a major challenge in all settings due to limited support by political and healthcare leaders, and human and financial constraints. In addition, the COVID-19 pandemic challenged already well-established programs. By enforcing sustained implementation by dedicated, cross-disciplinary healthcare personnel with a broad skill set, a reduction in healthcare-associated infections and multidrug-resistant pathogens can be achieved, leading ultimately to improved patient safety.

Patient Admission and Mechanical Ventilator Allocation Decision-Making Processes by Frontline Medical Professionals in a Japanese ICU During the COVID-19 Pandemic: A Qualitative Study

During the COVID-19 pandemic, the need to triage COVID-19 patients in ICUs emerged globally. Triage guidelines were established in many countries; however, the actual triage decision-making processes and decisions themselves made by frontline medical providers may not have exactly reflected those guidelines. Despite the need to understand decisions and processes in practice regarding patient ICU admission and mechanical ventilator usage to identify areas of improvement for medical care provision, such research is limited. This qualitative study was conducted to identify the decision-making processes regarding COVID-19 patient ICU admissions and mechanical ventilator allocation by frontline medical providers and issues associated with those processes in an ICU during the COVID-19 pandemic. Semi-structured, in-depth interviews were conducted with ICU physicians and nurses working at an urban tertiary referral hospital in Japan between February and April 2022. Patient characteristics that influenced triage decisions made by physicians and the interaction between physicians, nurses, and senior management staff upon making such decisions are discussed in this article. An implicated issue was the lack of legal support for Japanese physicians to practice withdrawal of life-sustaining treatments even during emergencies. Another issue was the impact of non-clinical forces-likely specific to health emergencies-on physicians' decisions regarding mechanical ventilator allocation, where such forces imposed a significant mental burden on the medical providers. We consider public policy and legal implications for future pandemics.

Systematic review: Safety of surgical male circumcision in context of HIV prevention public health programmes

Background: Since the recommendation of voluntary medical male circumcision (VMMC) to reduce the risk of heterosexually acquired HIV, a number of adolescent boys and men in 15 priority countries in Africa have been circumcised. Our primary goal was to identify the incidence of adverse events (AEs) associated with VMMC and to assess the safety profile among adolescent boys 10 - 14 years. Methods: We searched the databases MEDLINE and Embase, WHO, and conference abstracts from 2005 to 2019. The incidence of AEs was estimated by type of AE, size of study and age. Results: We retained 40 studies. Severe and moderate AEs overall were estimated at 0.30 per 100 VMMC clients with wide variability per study type. A higher rate was noted in small and moderate scale programmes and device method research studies compared with larger scale programmes. There was a limited number of studies reporting AEs among younger adolescent boys and they had higher infection-related AEs than those aged 20 years and older. Case studies noted rare AEs such as necrotizing fasciitis, tetanus, and glans injury. Conclusions: AE rates were comparable to those from the randomized controlled trials (RCTs) that led to recommendations and implementation of VMMC in high HIV burden countries, despite being implemented in low resource settings. Clients over time have increasingly included adolescents under the age of 15 years. Studies suggest potentially higher risks in this age group. As VMMC services are sustained, patient safety surveillance systems and promoting a patient safety culture are crucial to identify and mitigate potential harms from medical male circumcision.

Systematic review: Safety of surgical male circumcision in context of HIV prevention public health programmes

Background: Since the recommendation of voluntary medical male circumcision (VMMC) to reduce the risk of heterosexually acquired HIV, a number of adolescent boys and men in 15 priority countries in Africa have been circumcised. Our primary goal was to identify the incidence of adverse events (AEs) associated with VMMC and to assess the safety profile among adolescent boys 10 - 14 years. Methods: We searched the databases MEDLINE and Embase, WHO, and conference abstracts from 2005 to 2019. The incidence of AEs was estimated by type of AE, size of study and age. Results: We retained 40 studies. Severe and moderate AEs overall were estimated at 0.30 per 100 VMMC clients with wide variability per study type. A higher rate was noted in small and moderate scale programmes and device method research studies compared with larger scale programmes. There was a limited number of studies reporting AEs among younger adolescent boys and they had higher infection-related AEs than those aged 20 years and older. Case studies noted rare AEs such as necrotizing fasciitis, tetanus, and glans injury. Conclusions: AE rates were comparable to those from the randomized controlled trials (RCTs) that led to recommendations and implementation of VMMC in high HIV burden countries, despite being implemented in low resource settings. Clients over time have increasingly included adolescents under the age of 15 years. Studies suggest potentially higher risks in this age group. As VMMC services are sustained, patient safety surveillance systems and promoting a patient safety culture are crucial to identify and mitigate potential harms from medical male circumcision.

1349. Lesson Learned from Investigators of Clinical Trials to Identify Therapeutics for COVID-19: Qualitative Study

Background

Implementation of high-quality clinical trials especially early in the pandemic caused burden on clinical investigators given lack infrastructure, networks and systematic supports. To prepare for future pandemic, we investigated facilitator and obstacles that enable investigators to operate clinical trials for COIVD-19 in Japan.

Methods

We conducted individual semistructured qualitative interviews to assess the process of how clinical trials for COVID-19 were planned and implemented at the early stage of pandemic. Clinical investigators were primarily selected through purposive sampling to ensure that participants involved in the clinical trials were well covered. Additional participants were identified using snowball sampling. Interviews were analyzed using qualitative descriptive method.

Results

Through interviews, we identify factors that can impact on conduct clinical trials in infectious diseases field during health emergency in Japan (Figure). First, there are obstacles in rolling out clinical trials and this theme was further divided into two subthemes: obstacles in system(such as lack of regulatory frameworks to support trials, lack of clinical trial networks/platform, and understanding and attitude of the public to clinical trial); and obstacles in clinical level (such as limited resource for non-academic hospitals to implement clinical trials, and lack of trained experienced researchers and coordinators with regards to clinical trials). Secondary, a few factors that facilitate clinical trials exist. Not only governmental and organizational commitment but also presence of physicians and other healthcare professional interested in conducting trials are the key for facilitate clinical trials.

Facilitators and obstacles to implement clinical trials for COVID-19 therapeutics

Conclusion

In this qualitative study, clinical investigators in Japan who conducted clinical trials recognized both obstacles and facilitators. System level obstacles likely led to the obstacles in clinical level. Our finding emphasizes importance for health care policies to respond to such insight from front line clinical investigators to encourage systemwide efforts to facilitate and develop transparent clinical trials during future pandemic.

Disclosures

All Authors: No reported disclosures.

Incidence and length of outbreak period of COVID-19 and population density in comparison with seasonal influenza in Japan

Objectives

There is no consensus regarding the impact of population density on the transmission of respiratory viral infections such as COVID-19 and seasonal influenza. Our study aimed to determine the correlation between population density and the incidence and duration of COVID-19 transmission.

Methods

Publicly available data for confirmed COVID-19 cases in Japan, from January 2020 through November 2021, were retrospectively collected. The average numbers of seasonal influenza cases reported in the national database from 2013-2014 through 2019-2020 were identified. Using data for COVID-19 and seasonal influenza population density and incidence rates (age-adjusted), the Pearson's correlation coefficient was determined.

Results

A significant positive correlation between log population density and length of outbreak period was observed for COVID-19 (r = 0.734; p < 0.001) but not for seasonal influenza. Additionally, a significant linear correlation was observed between population density and age-adjusted incidence rate for COVID-19 (r = 0.692; p < 0.001) but not for seasonal influenza.

Conclusions

In Japan, areas with high population density experienced a prolonged and more intense COVID-19 outbreak compared with areas with low population density. This was not observed with seasonal influenza, suggesting that public health measures against COVID-19 should be tailored according to population density.

Epidemiological factors associated with COVID-19 clusters in medical and social welfare facilities

Characteristics of COVID-19 clusters in medical and social welfare facilities, and factors associated with cluster size are still not fully understood. We reviewed COVID-19 cases identified from January 15 to April 30 of 2020 in Japan, and analyzed factors associated with cluster size in medical and social welfare facilities. In the study, COVID-19 clusters were identified in 56 medical and 34 social welfare facilities. Numbers of cases in those facilities reached their peaks after the peak of general population. Duration of occurrence of new cases in clusters showed a positive correlation with the number of cases in both types of facilities (rho = 0.44, p < 0.001; and rho = 0.69, p < 0.001, respectively). However, number of days between the first case in the prefecture and the onset of clusters showed a negative correlation with the number of cases only in clusters in social welfare facilities (rho = -0.4, p = 0.004). Our results suggested that COVID-19 cases in those facilities were prevalent in the latter phase of the community transmissions, although the underlying mechanisms for such trend could be different between medical and social welfare facilities.

Why participation in an international clinical trial platform matters during a pandemic? Launching REMAP-CAP in Japan

REMAP-CAP, a randomized, embedded, multifactorial adaptive platform trial for community-acquired pneumonia, is an international clinical trial that is rapidly expanding its scope and scale in response to the COVID-19 pandemic. Japan is now joining REMAP-CAP with endorsement from Japanese academic societies. Commitment to REMAP-CAP can significantly contribute to population health through timely identification of optimal COVID-19 therapeutics. Additionally, it will promote the establishment of a national and global network of clinical trials to tackle future pandemics of emerging and re-emerging infectious diseases, in collaboration with multiple stakeholders, including front-line healthcare workers, governmental agencies, regulatory authorities, and academic societies.

Narrative Review: The Process of Expanding the Manual of Antimicrobial Stewardship by the Government of Japan

The Ministry of Health, Labour and Welfare has published the Manual of Antimicrobial Stewardship (1st edition) in June 2017 to improve the prescribing practice of antimicrobials for immunocompetent adult and pediatric (both school-aged and older children) patients. Due to the increasing demand for further promoting outpatient antimicrobial stewardship, we conducted a literature and national guideline review to identify the area of need. The results of our review revealed a high antimicrobial prescription rate in the Japanese pediatric population. Furthermore, although the Japanese clinical guidelines/guidance covered the fields of almost all infectious diseases, no system exists to estimate the incidence and treatment patterns of important infectious diseases such as asymptomatic bacteriuria, skin and soft tissue infections, and dental practices in Japan. Therefore, addressing the issues of both establishing surveillance systems and the implementation of guidelines/guidance can be the next step to promote further outpatient antimicrobial stewardship.

The Flight Evacuation Mission for COVID-19 from Wuhan, China to Tokyo, Japan from January 28 to February 17, 2020

Multiple countries have reported evacuation missions to repatriate their citizens in the early phase of the emergence of COVID-19 from China. However, a paucity of data exists on how to optimally execute an evacuation while balancing the risk of transmission during the flight and avoiding spread to the evacuees' home countries. We describe the collective findings of the flight evacuation mission from Wuhan, China to Tokyo, Japan from January 28 to February 17, 2020. The evacuation team established the evacuation processing flow, including a focused health questionnaire, temperature monitoring, ticketing and check-in, and boarding procedure planning. The evacuees were seated according to pre-planned zones. Additionally, to facilitate the triage of evacuees for medical needs, we conducted in-flight quarantine to determine the disposition of the evacuees. All evacuees, regardless of their health condition, were required to perform rigorous hand hygiene frequently and to wear surgical masks throughout the flight. We implemented strict infection prevention and control throughout the mission, including in-flight quarantine. The pre-planned protocol and vigilant observation during the flight were crucial elements of this mission. Our experience is of value in developing a more refined plan for the next outbreak.

Clusters of Coronavirus Disease in Communities, Japan, January-April 2020

We analyzed 3,184 cases of coronavirus disease in Japan and identified 61 case-clusters in healthcare and other care facilities, restaurants and bars, workplaces, and music events. We also identified 22 probable primary case-patients for the clusters; most were 20–39 years of age and presymptomatic or asymptomatic at virus transmission.

Infectious Disease Emergency Specialist (IDES) Training Program in Japan: an innovative governmental challenge to respond to global public health emergencies

In 2015, Japan created a unique governmental program to train experts in health emergencies called Infectious Disease Emergency Specialist (IDES). This is a concept paper to set out the goal and structure of the program, and to describe the achievement and the way forward to further contribute to global health security. The IDES program background, mission, structure, achievement, and future directions were reviewed and discussed by the IDES trainees, graduates, and program coordinators/supervisors. Since 2015, thirteen Japanese medical doctors have graduated from the program while five are currently in training. The IDES core competencies were identified in the context of a wide range of skillsets required for health emergencies. A large national and global network has been created through the training. Coordinated work with surge capacity of experts is of paramount importance to prepare for and respond to public health emergencies. The IDES program can be a good model to many other governments, and contribute to global health security.

Short-Term Incidence of Sequelae of HCV Infection Among Medicaid Beneficiaries in Oregon

OBJECTIVES

Given the known high morbidity and mortality of hepatitis C virus (HCV) infection in Oregon, we sought to develop a practical method of estimating the severe sequelae of HCV infection among Medicaid beneficiaries in Oregon.

METHODS

We assembled a retrospective cohort that identified all Oregon Medicaid beneficiaries with HCV infection enrolled for at least 1 year during 2009-2013. We linked this cohort to 3 data sets to identify HCV-related deaths, cases of hepatocellular carcinoma (HCC), and first hospitalizations for advanced liver disease (ALD). We calculated incidence density rates and used multivariable Cox regression modeling to calculate adjusted hazard ratios (aHRs) to evaluate the association between demographic characteristics (birth year, sex, race, ethnicity) and these 3 outcomes.

RESULTS

Of 11 790 Oregon Medicaid beneficiaries with HCV infection, 474 (4.0%) had an HCV-related death, 156 (1.3%) had HCC, and 596 (5.1%) had a first hospitalization for ALD. Adjusted hazard ratios for deaths were 2.2 (95% confidence interval [CI], 1.6-2.8) among persons born in 1945 through 1965 (vs persons born after 1965), 2.1 (95% CI, 1.7-2.5) among males (vs females), and 1.9 (95% CI, 1.2-2.9) among Asian/Pacific Islanders and 2.2 (95% CI, 1.5-3.2) among American Indian/Alaska Natives (vs white persons). The same risk groups had significant aHRs for first hospitalizations for ALD. Persons born before 1945 (aHR = 17.0; 95% CI, 5.2-55.8) and in 1945 through 1965 (aHR = 12.8; 95% CI, 4.1-40.3) vs born after 1965, males (aHR = 3.3; 95% CI, 2.3-4.8) vs females, and Asian/Pacific Islanders (aHR = 3.9; 95% CI, 2.3-6.7) vs white persons had higher risks for HCC.

CONCLUSIONS

Continued assessments using the methods piloted in this study will allow Oregon to monitor trends in severe sequelae of HCV infection over time.

First Major Practical Step toward Appropriate Antimicrobial Use by the Government of Japan

Antimicrobial resistance (AMR) is one of the top public health issues in Japan. Since Japan published the national action plan on AMR in 2016, its implementation has been a major focus of the Ministry of Health, Labour and Welfare. The ministry recently published the first edition of its Manual of Antimicrobial Stewardship (including an English version), a narrative review with a particular focus on the outpatient setting of primary care and 2 common infectious disease conditions. This is one of the very few occasions in which the ministry has proactively set out clinical guidance for healthcare delivery at the facility level. Implementation of the manual is further supported by a change in Japan's social health insurance coverage.

Multimorbidity and Functional Limitations Among Adults 65 or Older, NHANES 2005-2012

Introduction

The development of functional limitations among adults aged 65 or older has profound effects on individual and population resources. Improved understanding of the relationship between functional limitations and co-occurring chronic diseases (multimorbidity) is an emerging area of interest. The objective of this study was to investigate the association between multimorbidity and functional limitations among community-dwelling adults 65 or older in the United States and explore factors that modify this association.

Methods

We conducted a cross-sectional analysis of adults aged 65 or older using data from the National Health and Nutrition Examination Survey (NHANES) from 2005 through 2012. We used negative binomial regression to estimate the association between multimorbidity (≥2 concurrent diseases) and functional limitations and to determine whether the association differed by sex or age.

Results

The prevalence of multimorbidity in this population was 67% (95% confidence interval [CI], 65%–68%). Each additional chronic condition was associated with an increase in the number of functional limitations, and the association was stronger among those aged 75 or older than among those aged 65 to 74. For those aged 65 to 74, each additional chronic condition was associated with 1.35 (95% CI, 1.27–1.43) times the number of functional limitations for men and 1.62 times (95% CI, 1.31–2.02) the number of functional limitations for women. For those 75 or older, the associations increased to 1.71 (95% CI, 1.35–2.16) for men and 2.06 (95% CI, 1.51–2.81) for women for each additional chronic condition.

Conclusion

Multimorbidity was associated with increases in functional limitations, and the associations were stronger among women than among men and among adults aged 75 or older than among those aged 65 to 74. These findings underscore the importance of addressing age and sex differences when formulating prevention strategies.

Interventions to Improve Pharmacological Adherence Among Adults With Psychotic Spectrum Disorders and Bipolar Disorder: A Systematic Review

BACKGROUND

It is unclear as to which interventions are effective at improving medication adherence in individuals with serious and persistent mental illness. The goal of this systematic review is to synthesize evidence examining the effectiveness, harms, and costs of interventions to improve medication adherence in patients with psychotic spectrum disorders and bipolar disorder.

METHODS

We conducted a systematic search of several electronic databases through January 2015 using a structured search strategy. Studies were included if they involved adult patients in general mental health settings, reported both measures of medication adherence and clinical outcomes, and were of sufficient methodological rigor. Studies were quality assessed and synthesized using established methods.

RESULTS

We identified 24 studies that met inclusion criteria. Overall, 20 studies addressed interventions in patients with psychotic spectrum disorders. These interventions varied widely, with generally mixed findings contributing to low or insufficient strength of evidence; studies involving family members and technology interventions were the most consistently associated with a positive effect; however, the strength of the evidence was low because of intervention heterogeneity. The evidence was insufficient to determine the effectiveness of interventions in patients with bipolar disorder.

CONCLUSIONS

In individuals with psychotic spectrum disorders, interventions with family members or technology had the most consistent positive effect on adherence, although replication with objective adherence measures along with evaluation of harms and costs is needed. There was insufficient evidence to draw conclusions about interventions in individuals with bipolar disorder.

Is a single positive blood culture for Enterococcus species representative of infection or contamination?

Data on the clinical outcomes of patients with a single compared with multiple positive blood cultures for Enterococcus species is limited. We undertook a retrospective cohort study in adults with at least one positive blood culture for Enterococcus species in a single institution. Clinical outcomes included death and elimination of infection. We included 471 positive blood cultures from 206 enterococcal positive blood culture episodes in 189 patients. Multiple positive blood cultures for Enterococcus species occurred in 110/206 (53.4 %) episodes; 31.6 % of patients had diabetes mellitus; 42.9 % of patients had solid or hematologic malignancy; 26.5 % of patients were solid organ transplant recipients; hospital-acquired and healthcare-associated acquisition represented 55.3 % and 33.0 % of episodes, respectively. Thirty-five patients died and 110 episodes of enterococcal bloodstream infection were successfully treated. In the multivariable analysis, multiple positive blood cultures were not statistically significantly associated with an increased likelihood of in-hospital death [odds ratio (OR) 1.00, 95 % confidence interval (CI) 0.42-2.40] or elimination (OR 1.41, 95 % CI 0.76-2.64) compared with single positive blood cultures. Hematologic malignancy and diabetes mellitus were independently associated with in-hospital death (OR 2.83, 95 % Cl 1.02-7.82; OR 2.79, 95 % Cl 1.16-6.70, respectively). Infectious disease consultation was associated with a greater likelihood of elimination (OR 2.50, 95 % Cl 1.32-4.72). The clinical outcomes of patients with single versus multiple positive blood cultures with Enterococcus species were similar in our institution. Further studies should examine efficient methods to detect contamination versus true infection.

Human immunodeficiency virus testing pitfalls and clinical suspicion

Universal human immunodeficiency virus (HIV) screening was recommended in 2012, and major improvements in HIV testing have occurred in the past decade, but identification of HIV infected individuals remains inadequate in the United States. We report the case of a seronegative HIV-infected man who despite clinical and laboratory findings of acquired immunodeficiency syndrome,repeatedly tested nonreactive to third-generation HIV enzyme immunoassays (EIAs) and Western blot testing. Serologic diagnosis in this case required fourth-generation EIA testing due to the seronegativity of standard testing. The fourth-generation HIV EIA was positive presumably because it detects p24 HIV antigen as well as antibodies, unlike rapid HIV tests and third-generation HIV EIAs.This case highlights not only the importance of frontline providers to understand the different testing methodologies for HIV screening and their limitations but the importance of clinical suspicion as well.

Treatment of recurrent Clostridium difficile infection: a systematic review

BACKGROUND

Clostridium difficile infection (CDI) recurs in nearly one-third of patients who develop an initial infection. Recurrent CDI (RCDI) is associated with considerable morbidity, mortality, and cost. Treatment for RCDI has not been not well examined.

METHODS

A systematic review.

RESULTS

Sixty-four articles were identified evaluating eight different treatment approaches: metronidazole, vancomycin, fidaxomicin, nitazoxanide, rifampin, immunoglobulins, probiotics, and fecal bacteriotherapy. The meta-analysis found vancomycin to have a similar efficacy to metronidazole, although studies used varying doses and durations of therapy. Fidaxomicin was slightly more efficacious than vancomycin, though the number of studies was small. Good evidence for probiotics was limited. Fecal bacteriotherapy was found to be highly efficacious in a single randomized trial.

CONCLUSION

Metronidazole and vancomycin have good evidence for use in RCDI but heterogeneity in treatment duration and dose precludes robust conclusions. Fidaxomicin may have a role in treatment, but evidence is limited to subgroup analyses. Fecal bacteriotherapy was the most efficacious. Saccharomyces boulardii may have a role as adjunctive treatment.