Antimicrobial Resistance & Infection Control

BackgroundPreoperative overnight fasting of patients (no oral intake from midnight until the time of surgery) is a potentially harmful practice; nevertheless, it remains common. Prolonged preoperative fasting is frequent, at times up to 24 hours of fluid and nutrition deprivation. International guidelines recommend reduced fasting time to improve patient outcomes, but this evidence is not well implemented. This study investigated clinician perspectives on two interventions designed to reduce preoperative fasting. MethodsThe qualitative study was informed by the Consolidated Framework for Implementation Research (CFIR). Semi-structured interviews were conducted virtually or in person, with a purposive sample of perioperative health professionals. Thematic analysis revealed codes, some of which were specific to the two reduced fasting interventions (SipTilSend and oral carbohydrate loading), organised according to the CFIR constructs. Results and ConclusionsTwenty-one multidisciplinary clinicians were interviewed. Within the CFIR domains, adaptability enabled the tailoring of interventions to clinical contexts, while governance and policy updates supported adoption (Innovation). Progressive anaesthesia team leaders and leadership engagement drove change (Individuals). However, outdated policies and disincentives hindered progress (Outer Setting). Barriers included a lack of knowledge, while knowledge dissemination and clinician commitment to patient safety facilitated uptake (Inner setting). Champions among anaesthesia leaders and perioperative interdisciplinary collaboration played key roles in implementation success (Process). University of Newcastle Human Research and Ethics Committee Approval No: H-2021-0328

Background Peripheral intravenous cannulation is common procedure in neonatal care, yet it carries a significant risk of local complications that can compromise therapy and prolong hospital stay. Understanding the timing and predictors of Peripheral intravenous cannulation related local complications is crucial for improving neonatal outcomes. This study aimed to determine the incidence, timing, and predictors of Peripheral intravenous cannulation related local complications among neonates admitted to public hospitals in the Tigray, northern Ethiopia. Methods A prospective cohort study was conducted among 528 neonates who underwent peripheral intravenous cannulation. Data were collected using structured questionnaires and observational checklists. Neonates were followed for up to 96 hours. Cox proportional hazards regression was used to identify predictors of local peripheral intravenous cannulation related complications, with Kaplan Meier analysis to estimate complication free survival. Model assumption was assessed using Schoenfeld residuals and goodness of fit evaluated by Cox-Snell residuals, with variables showing p < 0.05 in the multivariable model considered statistically significant. Result The overall incidence of local peripheral intravenous cannulation -related complications among neonates was 41%, yielding an overall incidence rate of 8.85 per 1,000 catheter-hours. The median time to complication was 78 hours (95% CI: 67-80). The multivariable analysis identified the following independent predictors: chronic illness (AHR=1.54, 95% CI: 1.15-2.07), absence of saline flushing (AHR =1.83, 95% CI: 1.39-2.41), non-visible veins (AHR =2.07, 95% CI: 1.55-2.76), three or more insertion attempts (AHR =1.85, 95% CI: 1.15-2.98), cannula placement in the leg (AHR =1.84, 95% CI: 1.28-2.64), and cubital fossa (AHR =1.62, 95% CI: 1.10-2.39). Conclusion Local Peripheral intravenous cannulation complications in neonates are common and occur early, particularly among high-risk groups. Intervention such as routine IV-line flushing, careful vein selection, minimizing repeated insertion attempts, and avoiding high risk insertion sites can reduce complications. Close monitoring of neonates with chronic conditions and adherence to cannula replacement guidelines are recommended. Ongoing training for health care providers is essential to improve Peripheral intravenous cannulation care and neonatal outcomes.

IntroductionHealthcare-associated infections (HAIs) and antimicrobial resistance (AMR) are critical global challenges. Antimicrobial Stewardship Programs (ASPs) aim to optimize antibiotic use and reduce resistance. This study evaluates carbapenem stewardship compliance in open-heart surgery patients at Shaheed Rajaie Cardiovascular Medical and Research Center, Tehran, emphasizing improved infection control and antibiotic management. MethodologyThis descriptive, cross-sectional study assessed carbapenem antibiotic use compliance with national guidelines in open-heart surgery patients at Shaheed Rajaie Cardiovascular Medical Center, Tehran. Seventy patients were selected, and data on demographics, clinical factors, microbiology, and antibiotic use were analyzed using SPSS 26 to evaluate compliance rates and prescribing factors. ResultsThis study analyzed data from 70 patients undergoing open-heart surgery at a cardiovascular hospital in Tehran. The cohort had an equal gender distribution and a mean age of 59.15 years (SD: 12.0). Of the procedures, 51.43% were elective, while 48.57% were emergencies. The most common surgeries included CABG (45.71%) and valvular procedures (30%). Meropenem was the most prescribed antibiotic (92.9%), with prophylactic use noted in 78.57% intraoperatively. Positive cultures identified Candida albicans (32.7%), Klebsiella pneumoniae (29.8%), and Staphylococcus aureus (22.6%) as predominant pathogens. Serum creatinine levels exceeded the normal range in 55.7% of patients, necessitating dosage adjustments. Antibiotic side effects led to treatment discontinuation in 15.7% of cases. ConclusionThis study highlights a high level of rational carbapenem use in a specialized cardiac surgery ICU, with prescribing guided by infectious disease consultations and adherence to guidelines. Implementing antibiotic stewardship programs can further optimize carbapenem use, reduce antibiotic resistance, and improve treatment outcomes, emphasizing the importance of individualized infection management and monitoring in cardiac surgery patients.

ObjectivesThis review aims to synthesise studies on health and social care professionals (HCPs) knowledge, attitudes, and practices (KAP) regarding infection management, infection prevention and control, antimicrobial use, stewardship, and resistance to inform future research and policy. MethodIn January 2024, we conducted a comprehensive search in Medline, Embase, Web of Science, and CINAHL to identify studies on health and social care professionals KAP regarding infection management, prevention and control, antimicrobial use, stewardship, and resistance. After deduplication, the initial screening was conducted in Rayyan, with 10% checked for accuracy. Two reviewers independently assessed full texts. Data extraction was performed by one and verified by another reviewer. Quality assessment was completed by one reviewer, with 20% checked for accuracy. We included relevant studies published from 2016 onwards focusing on those conducted in the UK and in countries with comparable settings. Finally, a narrative synthesis was carried out due to significant differences between studies. ResultsOut of 10,990 unique records identified, 113 studies with diverse participants and settings were included. The findings showed substantial variation in KAP measures, complicating direct comparisons between studies. Some studies assessed objective knowledge(N=40) while most measured perceived knowledge(N=41), revelling discrepancies between the two. Attitude assessments revealed widespread consensus on the harms of inappropriate antimicrobial use, though willingness to participate in antimicrobial stewardship (AMS) activities varied by profession. Practice behaviour assessment indicated varying hand-hygiene compliance and AMS implementation, along with significant concerns about inappropriate antibiotic prescribing. ConclusionThe review highlights significant gaps in healthcare professionals KAP regarding infection prevention and antimicrobial stewardship, with variations across professions. This underscores the need for targeted interventions. Additionally, standardised KAP assessment measures are essential to enhance comparability across different contexts. These findings provide a foundation for future research and policy initiatives aimed at combating AMR.

BackgroundUrinary tract infections are among the adverse outcomes of urinary catheter placement. After the installation of a catheter, urinary tract infections happen more often than twice a day. Examining prevention strategies for UTIs in critical care units is the aim of this writing audit. MethodUse ProQuest, Scopus, and ScienceDirect to look up review literature. Urinary tract infections, prevention and management, and intensive care unit were the search terms used to find publications. Search parameters for full-text, open-access, English-language papers published between 2019 and 2023. ResultsThe studys findings indicate that adherence to patient information recording, installation and maintenance procedures, guidelines for the detection and prevention of CAUTI, staff education and good nursing practices, and the application of CAUTI prevention can all help lower the incidence of urinary tract infections. ConclusionHealthcare facilities need to have a program in place to avoid urinary tract infections brought on by catheter installation, as well as the best care possible for patients who use them. In order to solve the problem, all interdisciplinary teams must collaborate and analyze the issue using the PDSA methodology.

BackgroundMost studies investigating the association between hospital staff levels and mortality have focused on single professional groups, in particular nursing. However, single staff group studies might overestimate effects or neglect important contributions to patient safety from other staff groups. We aimed to examine the association between multiple clinical staff levels and case-mix adjusted patient mortality in English hospitals. Methods and FindingsThis retrospective observational study used routinely available data from all 138 National Health Service hospital trusts that provided general acute adult services in England between 2015 and 2019. Standardised mortality rates were derived from the Summary Hospital level Mortality Indicator dataset. Estimates for the effect of clinical staffing from the single staff models were generally higher than estimates from models with multiple staff groups. Using a multilevel negative binomial random effects model, hospitals with higher levels of medical and allied healthcare professional (AHP) staff had significantly lower mortality rates (1.04, 95%CI 1.02 to 1.06, and 1.04, 95%CI 1.02 to 1.06, respectively), while those with higher support staff had higher mortality rates (0.85, 95%CI 0.79 to 0.91 for nurse support, and 1.00, 95%CI 0.99 to 1.00 for AHP support), after adjusting for multiple staff groups and hospital characteristics. Estimates of staffing levels on mortality were higher in magnitude between- than within-hospitals, which were not statistically significant in a within-between random effects model. ConclusionsWe showed the importance of considering multiple staff groups simultaneously when examining the association between hospital mortality and clinical staffing levels. Despite not being included in previous workforce studies, AHP and AHP support levels have a significant impact on hospital mortality. As the main variation was seen between-as opposed to within-hospitals, structural recruitment and retention difficulties coupled with financial constraints could contribute to the effect of staffing levels on hospital mortality.

Background and objectiveVentilator-associated pneumonia (VAP), a leading cause of ICU mortality, remains prevalent in Southeast Asia, with limited data on critical care nurses knowledge and prevention practices in Malaysia. The purpose of this study was to assess knowledge, practices, barriers, and predictors of VAP prevention among critical care nurses in Sarawak, Malaysia. MethodsThis cross-sectional study was conducted from July to August 2023 at four public hospitals in Sarawak, Malaysia. Universal sampling was used to recruit nurses from various critical care units managing patients requiring ventilator support. A self-administered questionnaire, consisting of four sections, was employed to gather background information from nurses, assess their knowledge, perceived practices, and identify barriers related to VAP prevention. ResultsA total of 298 critical care nurses participated in the study. Of these, 66.8% demonstrated poor knowledge of ventilator-associated pneumonia (VAP) prevention; however, compliance with VAP prevention practices was significantly high at 76.5%. A Pearsons correlation test revealed a significant association between the nurses knowledge and their practices related to VAP prevention (p<0.001). Additionally, multiple regression analyses identified several significant predictors of critical care nurses perceived practices in VAP prevention, including their level of knowledge, type of unit, number of official beds, and sociodemographic factors (p <0.05). While knowledge positively influenced perceived practice, its impact was relatively minor compared to sociodemographic factors. Barriers to VAP prevention included nursing staff shortages, forgetfulness, and lack of written protocols. ConclusionsThe prevention of ventilator-associated pneumonia (VAP) is a multidisciplinary challenge, emphasizing the crucial role of critical care nurses. The findings from this study underscore the necessity for updated, evidence-based interventions that target knowledge gaps, perceived practices, and barriers to effective VAP prevention.

SynopsisO_ST_ABSObjectivesC_ST_ABSRecently, several methicillin-resistant Staphylococcus aureus (MRSA) community outbreaks occurred in the Netherlands, including one caused by an impetigo-causing MRSA strain resistant to fusidic acid. Since fusidic acid and flucloxacillin are the main treatment options for impetigo, increasing resistance limits treatment possibilities. We examined trends in fusidic acid resistance levels among MRSA isolates in the Netherlands. MethodsData on routine bacteriological cultures between 2016-2023 from 30 laboratories were extracted from the national surveillance system on antimicrobial resistance (ISIS-AR). Fusidic acid resistance rates per year were calculated both overall and per age group for all MRSA isolates, and more specific, for the subset of MRSA isolates from wound/pus/skin samples collected by general practitioners (WPS-GP-samples). Trends were determined using logistic regression and compared with trends among methicillin-susceptible S. aureus (MSSA) isolates. ResultsWe found an increasing trend in fusidic acid resistance among MRSA isolates from 15% in 2016 to 30% in 2023 (p<0.001) which differed significantly from the trend among MSSA isolates (p<0.001). An increase was also found in MRSA WPS-GP-samples, both among young children and the population of 13-64 years old, but not among elderly. The trends remained significant after exclusion of isolates associated with known fusidic acid-resistant MRSA outbreaks, both among MRSA isolates overall (OR = 1.10, 95% CI: 1.07-1.14, p<0.001) and among MRSA WPS-GP-samples (OR = 1.14, 1.07-1.21, p<0.001). ConclusionsIn conclusion, an increasing trend in fusidic acid resistance was found among MRSA isolates. Since impaired treatment for impetigo might ease the spread of (fusidic acid-resistant) MRSA, extra vigilance is warranted.

BackgroundEmergency obstetrics and newborn care training improves the knowledge and skills of healthcare professionals. However, there is limited evidence on training programs that had been informed by training needs analysis. The aim of the study was to determine training needs of registered midwives to inform a training program. MethodsA descriptive cross-sectional study design was used to collect data from N=202 midwives who worked at two comprehensive emergency obstetrics and neonatal care hospitals. Simple random sampling was used to select respondents. Ethics approval was obtained before conducting the study. Data were collected from November 2023 to January 2024 using an adapted self-administered Hennessy Hicks Training Needs Questionnaire. SPSS version 29 was used to analyze the data. Descriptive statistics, means and standard deviations were calculated. The differences between task importance and task performance were determined for each of the measured items. A paired sample t-test was used to establish the significance of the differences between each of the five category pairs with p=<.05. ResultsThe mean age of the 202 respondents was 38.06{+/-}6.9 years. The midwives predominantly fell into the age group 40-44 years (n=53, 22.2%), and they had an average of 5-9 years of work experience (n=75, 37.1%). Training needs were perceived for all the measured items. The research/ audit category emerged as the highest (M=2.23{+/-}1.05) training need, followed by clinical (1.94{+/-}0.55), administrative (1.70{+/-}1.03), communication (1.57{+/-}0.79) and supervisory tasks (1.14{+/-}0.76). Differences between each of the five category pairs were statistically significant with p=<.05. The highest specific training need was newborn resuscitation (n= 61, 30.2%). ConclusionThe study highlights the need for training on research and clinical tasks. RecommendationTailor training according to the identified needs for the effective management of emergency obstetrics and newborn complications.

ObjectiveTo evaluate intrapartum Group B Streptococcus (GBS) prophylaxis in women with documented penicillin allergy compared to women without penicillin allergy, and to investigate associated differences in neonatal outcomes. Study DesignThis retrospective cohort study included GBS positive pregnant women who had a vaginal delivery or cesarean section after trial of labor at >35 weeks of gestation at a high-volume urban hospital (2005-2018). Management of women who reported penicillin allergy was compared to women without a reported penicillin allergy. Maternal outcome was type of antibiotic administered for GBS prophylaxis (beta-lactam antibiotic prophylaxis defined as administration of penicillin, ampicillin, or cefazolin; alternative antibiotic prophylaxis defined as vancomycin or clindamycin). Neonatal outcomes included number of blood draws, antibiotic administration, neonatal intensive care unit (NICU) admission, and length of stay. Univariate analyses were performed. ResultsOf the 11,334 mother-neonate pairs meeting eligibility criteria, 1170 (10.3%) women had a documented penicillin allergy, and of these women 51 (4.4%) had a co-existing cephalosporin allergy. Among women with a reported penicillin allergy (n=1170), 49 (4.2%) received penicillin or ampicillin, 259 (22.1%) received cefazolin, 449 (38.4%) received clindamycin and 413 (35.3%) received vancomycin. Women with documented penicillin allergy were significantly more likely to receive alternative GBS prophylaxis compared to women without penicillin allergy (73.7% vs. 0.2%, p<0.01). Neonates of women who received alternative GBS prophylaxis had more lab draws compared to neonates of women who received beta-lactam antibiotic agents (20.8% vs. 17.3%, p<0.01). ConclusionPregnant women with documented penicillin allergy received alternative antibiotics for GBS prophylaxis at a significantly higher frequency than women without a penicillin allergy. This was associated with an increased frequency of blood draws among neonates of mothers with penicillin allergy.

IntroductionDisease surveillance is an essential element of an effective response to antimicrobial resistance (AMR). Associations between AMR cases and area-level drivers such as remoteness and socio-economic disadvantage have been observed, but spatial associations when modelling routinely collected surveillance data that are often imperfect or missing have not been previously possible. AimWe aimed to use spatial modelling to adjust for area-level variables and to enhance AMR surveillance for missing or sparse data, in an effort to provide clinicians and policy makers with more actionable epidemiological information. MethodsWe used monthly antimicrobial susceptibility data for methicillin-resistant Staphylococcus aureus (MRSA) from a surveillance system in Australia. MRSA was assessed for the effects of age, sex, socio-economic and access to healthcare services indices by fitting Bayesian spatial models. ResultsWe analysed data for 77, 760 MRSA isolates between 2016 and 2022. We observed significant spatial heterogeneity in MRSA and found significant associations with age, sex and remoteness, but not socio-economic status. MRSA infections were highest in adult females aged 16-60 living in very remote regions and lowest in senior males aged 60+ years living in inner regional areas.. ConclusionCurrent disease surveillance approaches for antimicrobial resistant infections have limited spatial comparability, are not timely, and at risk of sampling bias. Bayesian spatial models borrow information from neighbouring regions to adjust for unbalanced geographical information and can fill information gaps of current MRSA surveillance. Assessment of disease spatial variation is especially critical in settings which have diverse geography, dispersed populations or in regions with limited microbiological capacity.

BackgroundCOVID-19 and antimicrobial resistance (AMR) are two intersecting global public health crises. ObjectiveWe aim to describe the impact of the COVID-19 pandemic on AMR across healthcare settings. Data SourceA search was conducted in December 2021 in World Health Organizations COVID-19 Research Database with forward citation searching up to June 2022. Study EligibilityStudies evaluating the impact of COVID-19 on AMR in any population were included and influencing factors were extracted. MethodsPooling was done separately for Gram-negative and Gram-positive organisms. Random effects meta-analysis was performed. ResultsOf 6036 studies screened, 28 were included and 23 provided sufficient data for meta-analysis. The majority of studies focused on hospital settings (n=25, 89%). The COVID-19 pandemic was not associated with a change in the incidence density (IRR 0.99, 95% CI: 0.67 to 1.47) or proportion (RR 0.91, 95% CI: 0.55 to 1.49) of MRSA or VRE cases. A non-statistically significant increase was noted for resistant Gram-negatives (i.e., ESBL, CRE, MDR or carbapenem-resistant Pseudomonas or Acinetobacter species, IRR 1.64, 95% CI: 0.92 to 2.92; RR 1.08, 95% CI: 0.91 to 1.29). The absence of enhanced IPAC and/or ASP initiatives was associated with an increase in Gram-negative AMR (RR 1.11, 95%CI: 1.03 to 1.20), while studies that did report implementation of these initiatives noted no change in Gram-negative AMR (RR 0.80, 95%CI: 0.38 to 1.70). However, a test for subgroup differences showed no statistically significant difference between these groups (P=0.40) ConclusionThe COVID-19 pandemic could play an important role in the emergence and transmission of AMR, particularly for Gram-negative organisms in hospital settings. There is considerable heterogeneity in both the AMR metrics utilized and the rate of resistance reported across studies. These findings reinforce the need for strengthened infection prevention, antimicrobial stewardship, and AMR surveillance in the context of the COVID-19 pandemic. PROSPERO registration: CRD42022325831This research was carried out as part of routine work, no funding was received Data collection template, data, and analytic code are available upon request.

BackgroundNursing workload in intensive care units (ICUs) plays a crucial role in determining patient outcomes, quality of care, and healthcare system efficiency. The Nursing Activities Score (NAS) is a validated tool used internationally to measure nursing workload and estimate the proportion of nursing time required for patient care. However, evidence regarding its application in low- and middle-income countries (LMICs) remains limited. High nursing workload has been associated with increased mortality, prolonged ICU stay, and compromised patient safety. This study aimed to assess nursing workload using NAS in an ICU of a teaching hospital and evaluate its predictive ability for patient outcomes. MethodsThis observational study included 501 ICU patients admitted to a teaching hospital. NAS scores were recorded for each patient, and outcomes were categorized as survivors and non-survivors. The predictive ability of NAS was evaluated using Receiver Operating Characteristic (ROC) curve analysis. Model calibration was assessed using the Hosmer-Lemeshow goodness-of-fit test. Logistic regression analysis was performed to determine the association between NAS and mortality risk. The Mann-Whitney U test was used to compare NAS scores between survivors and non-survivors. ResultsThe median NAS score was 83.40 (IQR: 101.10-68.30; range: 39.2-134.4), indicating a high level of nursing workload in the ICU. ROC analysis showed that NAS had good predictive ability for patient outcomes with an AUROC of 0.838 (p < 0.001). The optimal cut-off value was 90.40, with 73.5% sensitivity and 73.1% specificity. The Hosmer-Lemeshow test (p = 0.422) indicated good model fit. Logistic regression analysis showed that higher NAS scores were significantly associated with increased mortality risk (Exp(B) = 0.937, p < 0.001). Non-survivors had significantly higher NAS scores (110.70) compared with survivors (76.20, p < 0.001). ConclusionNAS is a reliable tool for assessing ICU nursing workload and predicting patient outcomes. Higher NAS scores reflect greater patient severity and increased risk of mortality, highlighting the importance of optimized staffing and workload management in ICU settings. Author SummaryIntensive care units (ICUs) care for the most critically ill patients and require constant monitoring and complex nursing interventions. However, in many low- and middle-income countries, including Nepal, the number of available nurses is often insufficient compared with the high demand for intensive care services. This imbalance can increase nursing workload and may affect the quality and safety of patient care. Therefore, reliable tools are needed to measure nursing workload and help hospitals plan staffing more effectively. This study evaluated the Nursing Activities Score (NAS), a standardized tool used internationally to measure nursing workload, in the ICU of a teaching hospital. Data from 501 ICU patients were analyzed to determine the level of nursing workload and whether NAS could predict patient outcomes. The findings showed that the nursing workload was high, with a median NAS score of 83.4, indicating substantial nursing care requirements. Patients who did not survive had significantly higher NAS scores compared with survivors. NAS also showed good accuracy in predicting patient outcomes. These findings suggest that NAS is a useful tool for measuring nursing workload and identifying critically ill patients who require more intensive care. Using NAS in ICUs may help hospitals optimize staffing, improve patient safety, and support better critical care management in resource-limited settings.

The "Does longer peripheral intravenous catheter (PIVC) Length optimise Antimicrobial Delivery: a randomised controlled trial to reduce interruptions to intravenous antimicrobial delivery (The LEADER Study)", is a randomised controlled trial (RCT). This RCT aims to assess if long peripheral intravenous catheters (PIVCs) (4.5-6.4 cm) when compared with short-PIVCs (<4 cm) optimise antimicrobial delivery by reducing PIVC failure rates. The purpose for this document is to minimise bias and ensure transparency and internal validity for the findings of the trial, by defining and making publicly available the analysis approach prior to reviewing or analysing trial data. The statistical analysis plan (SAP) will inform analysis and reporting of the main effectiveness findings of the trial. It provides a detailed description of the primary and secondary trial outcomes and the methods for statistical comparison.

ObjectiveThe aim of this review is to highlight the efficacy of nurse-performed ultrasound guidance compared with the conventional cannulation technique in patients with difficult peripheral intravenous access. DesignA systematic litterature review. Data sourcesThe CINAHL and PubMed databases were searched for articles from the period 2011-2021. MethodThe following search words were used: peripheral intravenous AND ultrasonography OR ultrasound guided AND catheterization, peripheral/methods. The keyword catheterization, peripheral/methods was found via MeSH Terms (Medical Subject Headings) which PubMed recommended as keyword within the intervention of the conventional cannulation technique. Results2 out of 3 articles prove that success rate on the first attempt (primary outcome) was significantly higher in the nurse-performed ultrasound-guided technique compared with the conventional palpation technique. The results of the secondary outcomes; time consumption, complications, patient satisfaction and nurse satisfaction between the two groups proved to be heterogeneous. ConclusionNurse-performed ultrasound guidance in hospital wards increases the success rate in patients with difficult peripheral intravenous access.

AimThis detailed genomic study aimed to characterise multi-drug resistant-gram negative bacilli (MDR-GNB) intestinal and skin carriage in small vulnerable newborns and their paired mothers at a low-resource African hospital. MethodsThis cross-sectional cohort study was conducted at the only neonatal referral unit in The Gambia with genomic analysis at MRC Unit The Gambia at LSHTM. Neonates <2kg underwent skin and peri-anal carriage swab sampling weekly with paired maternal rectovaginal swabs. Prospective bacteriological culture used MacConkey agar with species identification by API20E and API20NE. All GNB isolates underwent whole genome sequencing on Illumina Miseq platform. Multi-Locus Sequence Typing and SNP-distance analysis were used to identify strain type and infer relatedness. Findings135 carriage swabs were obtained from 34 neonates and 21 paired mothers (21 neonate-mother dyads), yielding 137 GNB isolates of which 112 were high quality de novo assemblies. Neonatal MDR-GNB skin or intestinal carriage prevalence was 41% (14/34) at admission with 85% (11/13) new acquisition occurring by 7 days. Multiple MDR and ESBL - GNB species were carried by neonates at different timepoints, most frequently K. pneumoniae and E. coli, with heterogeneous strain diversity, no evidence of clonality and 111 distinct antibiotic resistance genes, mostly Beta-Lactams (Bla-AMPH, Bla-PBP, CTX-M-15, Bla- TEM-105). 76% (16/21) and 62% (13/21) of mothers had recto-vaginal carriage of at least 1 MDR-GNB and ESBL-GNB respectively, most commonly MDR-E. coli (76%, 16/21) and MDR-K. pneumoniae (24%, 5/21). Of 21 neonate-mother dyads only one had genetically identical isolates (E. coli ST131 and K. pneumoniae ST3476). ConclusionGambian hospitalised small vulnerable neonates exhibit high MDR and ESBL-GNB carriage prevalence with acquisition between birth and 7 days. The heterogeneous strain diversity and lack of matching isolates between mothers and newborns suggests multiple environmental sources may be important in transmission. Larger genomic studies to confirm these findings in similar resource limited settings is foundational to inform targeted surveillance and infection prevention control policies. What is known: - MDR-GNB, especially Klebsiella pneumoniae and Escherichia coli, are important causes of neonatal invasive infections and mortality in Africa, classified by WHO as pathogens of high priority for research - Neonatal MDR-GNB carriage is a pre-curser for invasive infection, with preterm, low-birth weight neonates ("Small Vulnerable Newborns") at greatest risk - Maternal MDR-GNB carriage is a risk factor for neonatal pathogen acquisition in Europe and other well-resourced settings, but a priority evidence gap exists for transmission pathways for small vulnerable African newborns What this study adds: - Hospitalised Gambian small vulnerable neonates have high carriage prevalence of MDR- and ESBL-GNB with acquisition occurring between birth and 7 days - Heterogeneous diversity of K. pneumoniae and E. coli strains suggests multiple environmental sources with no evidence of clonal outbreak - Beta-lactamase genes were most commonly identified with high rates of ESBL- and AMP-C gene production - Despite high maternal MDR-GNB carriage prevalence there is no genomic evidence indicating widespread transmission from mother to newborn

ProblemThe United States Healthcare Systems is burdened heavily by healthcare-associated infections (HAI), as they pose significant risks for increased mortality and morbidity. The most common type of HAI is urinary tract infection (UTI), and these infections are preventable (Strassle et al., 2019). According to the CDC (2021), 12-16% of hospitalized adults will at some point require catheterization; and each day an indwelling catheter remains in place increases the patients risks of adverse outcomes by 3-7%. CAUTIs have been linked to increased mortality and morbidity rates across the world. The Centers for Disease Control report urinary tract infections (UTI) lead to more than 13,000 deaths each year (Centers for Disease Control [cdc], 2021). ObjectiveThis quality improvement (QI) project will focus on the prevention of hospital-acquired UTIs, specifically those infections related to indwelling devices such as foley catheters. The purpose of this manuscript is to review the current evidence-based literature related to CAUTI prevention, trial an intervention that parallels the literature in a local hospital and evaluate those results. DesignThe researcher focused on the problem of CAUTI, analyzed current evidence-based practices related to prevention, developed a plan to execute a high-value improvement tool, and evaluated its effectiveness. SettingQI project took place in a local community hospital. The focus area was the medical-surgical ICU. ParticipantsThe participants were nursing staff and nursing managers on the medical surgical units, specifically those in positions with unique or direct involvement with insertion, removal, or monitoring of foley catheters. The subjects in this quality improvement project included adult patients hospitalized in the medical surgical intensive care unit (ICU). InterventionsA CAUTI GPS screening tool was used to identify current prevention practices and/or any roadblocks to the prevention of CAUTI within the facility. Then, TAP (targeted assessment for prevention) strategy was implemented, which prompted expedited removal of indwelling catheters and/or the use of external drainage devices where indicated. ResultsThere was a marked increase in attention to and prompt removal of indwelling foleys throughout the critical care unit. The facility had no hospital-acquired CAUTI during the project period. ConclusionsThere must be an impetus to inspire compliance. If healthcare workers adhere to prevention guidelines, CAUTIs are preventable. When leadership team members within hospital systems are enthusiastic about CAUTI prevention, the organization as a whole has increased motivation (Chenoweth et al., 2014).

SummaryO_ST_ABSBackgroundC_ST_ABSThe COVID-19 pandemic led to major disruptions in healthcare services at the hospital and community levels. The resulting impact on antibiotic resistance (ABR) in hospitals is difficult to predict. MethodsWe exploited data from the French national surveillance system over four years (2019-2022) including 414 hospitals across 12 French regions. We evaluated changes in annual antibiotic use compared to 2019 using multiple comparison tests. We also compiled a large dataset of 692,551 incident isolates for five antibiotic-bacterium pairs. Using negative binomial regression models accounting for autocorrelation and antibiotic use, we evaluated associations between resistant isolates incidence and COVID-19 indicators (pandemic periods or intubated COVID-19 patient prevalence). We investigated how these associations varied specifically in ICUs (n=85) and across geographical regions. FindingsThe use of some antibiotics, including azithromycin, imipenem and meropenem, significantly increased between 2020 and 2022. Concomitantly, the incidence of methicillin-resistant Staphylococcus aureus (up to 37%, 95% CI: 18-53%) and ESBL-producing Escherichia coli (up to 33%, 95% CI: 16-46%) isolates significantly decreased in hospitals and ICUs during the pandemic. A transient decrease in ICUs was also observed for ESBL-producing Klebsiella pneumoniae during periods of strong anti-COVID-19 interventions in the community (24%, 95% CI: 6-38%). No significant changes for ESBL-producing Enterobacter cloacae complex were observed. Very interestingly, the incidence of carbapenem-resistant Pseudomonas aeruginosa isolates was associated with COVID-19 intubation prevalence in hospitals (p<0.001) and ICUs (p<0.001), notably in the regions most affected by the pandemic. InterpretationOur results highlight strong modifications of antibiotic use and pathogen-specific global impacts of the COVID-19 pandemic on ABR in hospitals. Even though the biological mechanisms underlying between- species differences remain unclear, these results provide important insights into the potential impacts of a viral pandemic on ABR and support the need for pandemic preparedness in healthcare facilities. FundingANR-10-LABX-62-IBEID. Research in contextO_ST_ABSEvidence before this studyC_ST_ABSWe searched PubMed for articles in English published between Jan 1, 2020, and August 31, 2024 exploring national-scale changes in antibiotic resistance (ABR) within healthcare settings during the COVID-19 pandemic. Search terms for titles and abstracts were ("antibiotic resistance" OR "antimicrobial resistance" OR "bacterial resistance" OR "drug resistance" OR "MRSA" OR "ESBL" OR "carbapenem resistant") AND ("hospital" OR "healthcare") AND ("COVID-19" OR "SARS-CoV-2") AND ("national" OR "nationwide"). The search yielded 94 results. We identified 12 relevant studies after filtering out articles referring to viruses, parasites, or fungi, focusing on a single hospital, evaluating changes in antibiotic use only, assessing healthcare workers practices, or using qualitative approaches. All studies used either national surveillance data on antibiotic resistance or large multi-center cohorts of inpatients. Five studies showed a significant increase in MRSA, at least during the first wave of the COVID-19 pandemic, while two studies did not find changes at the national level compared to 2019. Interestingly, one study showed that the abandonment of infection prevention and control strategies that specifically target hospital-acquired MRSA infections was associated with an increase of these infections, regardless of COVID-19 admission prevalence. One study in Spain showed decreased resistance of P. aeruginosa to all tested antibiotics in 2022 compared to 2017, using point prevalence survey results. Conversely, one study focusing on US Veterans Affairs hospitals showed increased incidence and resistance of healthcare-associated carbapenem-resistant P. aeruginosa (CR-PA) infections during the pandemic. Most studies used univariate statistical approaches. Only two studies included COVID-19-related variables in their models; they found no association with MRSA or extended-spectrum cephalosporin-resistant E. coli and K. pneumoniae. Added value of this studyHere, we provide the first evaluation of the impact of the pandemic on antibiotic consumption and resistance for five antibiotic-bacterium pairs (MRSA, CR-PA, ESBL-producing E. coli, ESBL-producing K. pneumoniae, and ESBL-producing E. cloacae complex) in hospitals, at the national and regional scales. By analyzing French surveillance data from the SPARES database including 414 hospitals that represent up to 14% of French hospitals, we evaluated annual changes in antibiotic use and quantified the impacts at the weekly level of the COVID-19 pandemic on the incidence of five of the most prevalent resistant bacteria in France. Accounting for autocorrelation and antibiotic use, factors that were not considered in previous studies, we report a significant positive association between the weekly incidence of CR-PA isolates and the prevalence of intubated COVID-19 patients in the preceding weeks. Carbapenem use and intubation being risk factors of CR-PA infections, our results suggest a direct impact of the pandemic on CR-PA epidemiology. Inversely, we show that the incidence of ESBL-producing E. coli and MRSA isolates decreased after the start of the first pandemic wave at the hospital level but also in ICUs. The fine grain analysis across 12 French administrative regions revealed regional heterogeneities, but highlighted consistent associations in the regions most affected by the COVID-19 pandemic. Implications of all the available evidencePandemics not only destabilize healthcare systems by adding pressure and changing healthcare worker behaviors, but also influence the epidemiology of other infectious diseases as shown in our study. We specifically highlight the contrasting effects of the COVID-19 pandemic on ABR in French hospitals, associated with an increase in CR-PA isolate incidence but a general decrease in ESBL-producing E. coli and MRSA. This work highlights how national-scale hospital surveillance systems such as SPARES that collect data at the weekly level are key to capture the evolving impacts of pandemics. They also allow to generate hypotheses on the potential mechanisms of action of the pandemic on ABR epidemiology, as showcased by the analysis of CR-PA isolates incidence, and thereby participate in the improvement of healthcare systems in pandemic context.

BackgroundAccording to the European Center for Disease Prevention and Control (ECDC), the EU records an estimated 3.2 million healthcare associated infections (HAIs) and an associated 37,000 deaths annually. A significant proportion of the HAIs burden is attributable to multi-drug resistant organisms (MDROs). Infectious diseases remain top on the list of the leading causes of death globally with MDROs playing a significant role. Key amongst these organisms is Clostridium difficile and Klebsiella pneumoniae which belong to the broader group of ESKAPE pathogens. AimsThis review aimed at identifying literature on interventions targeting Clostridium difficile and Klebsiella pneumoniae, their key outcomes, and the extent to which behavioural theory has been applied in such interventions. MethodsThis scoping review was undertaken and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews (PRISMA-ScR) guidelines. The specific databases searched included MEDLINE, PubMed, Web of Science Core Collection, and CINAHL. The process for screening articles and data extraction was undertaken in duplicate by two reviewers. A narrative synthesis of the results is provided. ResultsThe review included 34 studies (16 studies on Clostridium difficile and 18 articles focussed on Klebsiella pneumoniae). The specific antimicrobial stewardship interventions identified include Education, Surveillance and Screening, Consultations, Audits, Policies and Protocols, Environmental measures, Bundles of care, Isolation precautions, as well as Notifications and alerts systems (ESCAPE-BIN). The identified outcomes include antimicrobial use, resistance rates, risk reduction, adherence to contact precautions, hospital stay, and time savings. Only one study incorporated Kotters stages of behaviour change and recorded the second largest (75%) sustained reduction in antimicrobials use whereas the remainder of the studies were devoid of behavioural approaches. The highest improvement (95%) in adherence isolation precautions was reported by an intervention involving the use of an IPC bundle and an environmental cleaning protocol. ConclusionThis scoping review identified the available evidence on antimicrobial the mitigation strategies for Clostridium difficile and Klebsiella pneumoniae in healthcare settings as well as the key outcomes. There is need for further investigations on the feasibility of behaviour-based approaches in improving adherence of health workers to interventions targeting Clostridium difficile and Klebsiella pneumoniae.

BackgroundHospitalized patients are at risk for developing hospital acquired infections. Active surveillance for bacterial colonization is effective at preventing infection but is resource-intensive and limited to high-risk units and a subset of high-risk pathogens. Colonization pressure (CP) for common pathogens has been associated with hospital acquired infection and can be calculated in real-time using data in the electronic health record. We aimed to assess the impact of CP on nosocomial acquisition for a range of drug susceptible and drug resistant pathogens, across an entire hospital system. MethodsWe conducted a retrospective matched cohort study of all inpatients admitted to a large regional integrated healthcare system between May 2015 and July 2024 who stayed in one room during the 30 day observation period. Cases had target organisms detected in any clinical or surveillance culture taken between 3 and 30 days after admission into their first room. Controls were matched on demographics, length of stay, prior surgery and 14 classes of antibiotic exposure. Our outcome was nosocomial acquisition of 11 common pathogens spread across enteric, skin and environmental niches. We applied conditional logistic regression and XGBoost to model nosocomial acquisition using as covariates the Elixhauser comorbidity index and CP, defined as the time-weighted prevalence of an organism in ward co-occupants over the previous 6 months. CP was calculated for 9 organism sets, including the Enterobacterales, ESBL Enterobacterales, vancomycin susceptible and resistant Enterococcus spp, C. difficile, methicillin susceptible Staphylococcus aureus (MSSA), methicillin resistant S. aureus (MRSA) and drug susceptible and drug resistant (DR) P. aeruginosa (PsA). FindingsOur pooled cohort included 14,923 cases matched to 28,480 controls. Hospital acquisition occurred four times more frequently for drug susceptible versus drug resistant organisms. Baseline characteristics were well matched between cases and controls. The strongest positive associations were between CPC. difficile and nosocomial acquisition of C. difficile (+32.5%, 95% CI +21.9% to +44.0%), CPESBL and ESBL K. pneumoniae (+29.4%, 95% CI +11.3% to +50.6%), and CPPsA-DR with drug resistant P. aeruginosa (+28.6%, 95% CI +14.0% to +45.0%). Among the skin flora, CPMSSA was associated with a +12.1% (95% CI +9.9% to +14.4%) increase in the odds of nosocomial acquisition of MSSA, CPMRSA was associated with a +6.7% (95% CI +1.3% to +12.5%) increase in the odds of MRSA. Negative associations were observed between organisms inhabiting different niches, including CPMSSA and ESBL K. pneumoniae (-7.9%, 95% CI -15.1% to -0.2%), and CPPsA-DR and vancomycin susceptible E. faecalis (-10.0%, 95% CI -15.6% to -4.0%). InterpretationA hospitalized patients odds of nosocomially acquiring a potential pathogen is associated with its prevalence among that patients ward co-occupants, regardless of the organisms drug resistance profile. Further research is necessary to understand the role of passive surveillance of CP for preventing infection. FundingLWS was supported by the NLM (2T15LM007092-31). ZW was supported with institutional funding from the Department of Population Medicine. TRP was supported by AHRQ (K08-HS030118). SK was supported by AHRQ (grant no. K08 HS027841-01A1).