BACKGROUND: The coronavirus disease 2019 (COVID-19) has swept the globe and is causing significant morbidity and mortality. Given that the virus is transmitted via droplets, open airway procedures such as bronchoscopy pose a significant risk to health-care workers (HCWs). The goal of this guideline was to examine the current evidence on the role of bronchoscopy during the COVID-19 pandemic and the optimal protection of patients and HCWs. STUDY DESIGN AND METHODS: A group of approved panelists developed key clinical questions by using the Population, Intervention, Comparator, and Outcome (PICO) format that addressed specific topics on bronchoscopy related to COVID-19 infection and transmission. MEDLINE (via PubMed) was systematically searched for relevant literature and references were screened for inclusion. Validated evaluation tools were used to assess the quality of studies and to grade the level of evidence to support each recommendation. When evidence did not exist, suggestions were developed based on consensus using the modified Delphi process. RESULTS: The systematic review and critical analysis of the literature based on six PICO questions resulted in six statements: one evidence-based graded recommendation and 5 ungraded consensus-based statements. INTERPRETATION: The evidence on the role of bronchoscopy during the COVID-19 pandemic is sparse. To maximize protection of patients and HCWs, bronchoscopy should be used sparingly in the evaluation and management of patients with suspected or confirmed COVID-19 infections. In an area where community transmission of COVID-19 infection is present, bronchoscopy should be deferred for nonurgent indications, and if necessary to perform, HCWs should wear personal protective equipment while performing the procedure even on asymptomatic patients.

Subglottic secretion drainage is associated with lower ventilator-associated pneumonia rates but does not clearly decrease duration of mechanical ventilation, length of stay, ventilator-associated events, mortality, or antibiotic usage. Further data are required to demonstrate the benefits of subglottic secretion drainage.

This cohort study compares the surgical site infection rate associated with laparoscopic colon surgery vs open-approach laparoscopy.

Objective:To determine whether oral vancomycin prophylaxis accompanying systemic antibiotics reduces the risk of relapse in patients with history of Clostridioides difficile infection (CDI).Design:Retrospective cohort study.Patients:Adult inpatients with a history of CDI who received systemic antibiotics in either of 2 hospitals between January 2009 and June 2015.Methods:We compared relapse rates in patients who started oral vancomycin concurrently with systemic antibiotics (exposed group) versus those who did not. We assessed for CDI relapse by toxin or nucleic acid testing at 90 days. We used inverse probability weighting and machine learning to adjust for confounders, to estimate propensity for treatment, and to calculate odds ratios for CDI relapse. We performed secondary analyses limited to toxin-positive relapses, patients with 1 versus >1 prior CDI episodes, and patients who received oral vancomycin on each antibiotic day.Results:CDI relapse occurred within 90 days in 19 of 193 exposed patients (9.8%) versus 53 of 567 unexposed patients (9.4%; unadjusted odds ratio [OR], 1.06; 95% confidence interval [CI], 0.60–1.81; adjusted OR, 0.63; 95% CI, 0.35–1.14). CDI relapses at 90 days were less frequent in exposed patients with only 1 prior episode of CDI (OR, 0.42; 95% CI, 0.19–0.93) but not in those with >1 prior episode (OR, 1.19; 95% CI, 0.42–3.33). Our findings were consistent with a lack of benefit of oral vancomycin when restricting results to toxin-positive relapses and to patients who received vancomycin each antibiotic day.Conclusions:Prophylactic oral vancomycin was not consistently associated with reduced risk of CDI relapse among hospitalized patients receiving systemic antibiotics. However, patients with only 1 prior CDI episode may benefit.

The Bristol stool form scale classifies the relative density of stool samples. In a prospective cohort study, we investigated the associations between stool density, C. difficile assay positivity, hospital-onset C. difficile infection, complications, and severity of C. difficile. We describe associations between the Bristol score, assay positivity, and clinical C. difficile infection. The Bristol stool scale is a graded visual scale of stool density (Table 1) (1). It is validated as a proxy for gastrointestinal transit times (2, 3) and used to define "diarrhea" by the European Society for Clinical Microbiology and Infectious Disease for Clostridium difficile infection (CDI) (4). At our institution, we require a specimen Bristol score of Ն5 to reduce inappropriate C. difficile testing. Our primary objective was to determine the relationship between Bristol scale score, C. difficile assay positivity, and hospital-onset CDI, and specifically, whether specimens of Bristol score 5 could be rejected for a low rate of positivity. Our secondary objective was to compare Bristol scores with rates of complications and severe hospital-onset CDI.We conducted a prospective cohort study of all stool specimens collected for C. difficile testing from adult inpatients at the Hospital of the University of Pennsylvania, a tertiary-care academic hospital, from 1 January 2013 through 31 October 2013. Approval was obtained from the University of Pennsylvania's Institutional Review Board. For refrigerated fresh stool specimens submitted for C. difficile testing, the Bristol score was documented in our laboratory information database by one of eight laboratory technologists. Two blinded inter-rater reliability studies were performed in May and July 2013 and analyzed by the Fleiss kappa test. Our C. difficile testing algorithm includes enzyme immunoassay (EIA) for glutamate dehydrogenase and toxins A/B (Techlab C. Diff Chek Complete; Alere, Orlando, FL), followed by a nucleic acid amplification test (NAAT) (Illumigene, Meridian Bioscience, Inc., Cincinnati, OH; changed to BD Max, Becton, Dickinson and Company, Sparks, MD, in August 2013) for indeterminate EIA results (glutamate dehydrogenase positive but toxin A/B negative). Internal studies of the relative sensitivities of the Illumigene and BD Max methods showed no significant performance differences. A comparison of the monthly fraction of positive specimens detected by a molecular assay for the same 5-month period (August to December) during 2012 (Illumigene used) and 2013 (BD Max used) showed no significant difference (53% versus 48%, P ϭ 0.4 by two-tailed nonpaired t test), concordant with published data on comparative test performance (5). Specimens with a Bristol score of Յ4 were rejected. We collected the assay result, type of assay (EIA or NAAT), date of testing, and patient admission dates from medical records. For positive assays, prospective medical record review was performed by infection preventionists. Cases of CDI were documented in the surveillance program Theradoc (Hos...

Typing studies suggest that most cases of hospital-onset Clostridium difficile infection (CDI) are unrelated to other cases of active disease in the hospital. New cases may instead be due to transmissions from asymptomatic carriers or progression of latent C. difficile present on admission to active infection. Direct exposure to antibiotics remains the primary risk factor for CDI but ward-level antibiotic use, antibiotic exposure of the prior room occupant, and C. difficile status of the prior room occupant increase risk for C. difficile acquisition while antibiotic exposure, gastric acid suppression, and immunosuppression increase risk for progression to infection. These insights suggest possible new approaches to prevent CDI, including screening to identify and isolate carriers, universal gloving, greater use of sporicidal cleaning methods, enhancing antibiotic and possibly proton pump inhibitor stewardship, and prescribing prophylactic vancomycin and/or probiotics to colonized patients to prevent progression from colonization to infection. We review current evidence and questions related to these interventions.

Background The Centers for Medicare and Medicaid Services (CMS) use colon surgical site infection (SSI) rates to rank hospitals and apply financial penalties. The CMS’ risk-adjustment model omits potentially impactful variables that might disadvantage hospitals with complex surgical populations. Methods We analyzed adult patients who underwent colon surgery within facilities associated with HCA Healthcare from 2014 to 2016. SSIs were identified from National Health Safety Network (NHSN) reporting. We trained and validated 3 SSI prediction models, using (1) current CMS model variables, including hospital-specific random effects (HCA-adapted CMS model); (2) demographics and claims-based comorbidities (expanded-claims model); and (3) demographics, claims-based comorbidities, and NHSN variables (claims-plus–electronic health record [EHR] model). Discrimination, calibration, and resulting rankings were compared among all models and the current CMS model with published coefficient values. Results We identified 39 468 colon surgeries in 149 hospitals, resulting in 1216 (3.1%) SSIs. Compared to the HCA-adapted CMS model, the expanded-claims model had similar performance (c-statistic, 0.65 vs 0.67, respectively), while the claims-plus-EHR model was more accurate (c-statistic, 0.70; 95% confidence interval, .67–.73; P = .004). The sampling variation, due to the low surgical volume and small number of infections, contributed 74% of the total variation in observed SSI rates between hospitals. When CMS model rankings were compared to those from the expanded-claims and claims-plus-EHR models, 18 (15%) and 26 (22%) hospitals changed quartiles, respectively, and 10 (8.3%) and 12 (10%) hospitals changed into or out of the lowest-performing quartile, respectively. Conclusions An expanded set of variables improved colon SSI risk predictions and quartile assignments, but low procedure volumes and SSI events remain a barrier to effectively comparing hospitals.

BACKGROUND Healthcare-associated infections (HAIs) cause significant morbidity in critically ill patients. An underappreciated but potentially modifiable risk factor for infection is sedation strategy. Recent trials suggest that choice of sedative agent, depth of sedation, and sedative management can influence HAI risk in mechanically ventilated patients. OBJECTIVE To better characterize the relationships between sedation strategies and infection. METHODS Systematic literature review. RESULTS We found 500 articles and accepted 70 for review. The 3 most common sedatives for mechanically ventilated patients (benzodiazepines, propofol, and dexmedetomidine) have different pharmacologic and immunomodulatory effects that may impact infection risk. Clinical data are limited but retrospective observational series have found associations between sedative use and pneumonia whereas prospective studies of sedative interruptions have reported possible decreases in bloodstream infections, pneumonia, and ventilator-associated events. CONCLUSION Infection rates appear to be highest with benzodiazepines, intermediate with propofol, and lowest with dexmedetomidine. More data are needed but studies thus far suggest that a better understanding of sedation practices and infection risk may help hospital epidemiologists and critical care practitioners find new ways to mitigate infection risk in critically ill patients. Infect Control Hosp Epidemiol 2016;1-9.