H ealth care-associated infections, associated with antibiotic resistance, lead to considerable morbidity, mortality, and costs. Methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) are the primary causes of these infections and are associated with worse outcomes than infections caused by antibiotic-susceptible S. aureus and Enterococcus. Although current interventions to prevent such infections focus on hand hygiene, compliance rates remain low. The use of gloves and gowns, however, may reduce the acquisition of antibiotic-susceptible and antibiotic-resistant bacteria by health care workers and decrease transmission to patients. This clusterrandomized trial was conducted to assess whether wearing gloves and gowns for all contact with intensive care unit (ICU) patients compared with the use of contract precautions only would reduce acquisition rates of MRSA and VRE infections.The study was conducted in 20 medical and surgical ICUs in 20 US hospitals during 2012. In the intervention group (10 ICUs), health care workers wore gloves and gowns for all patient contact and when entering any patient room. The control group workers (10 ICUs) wore gloves and gowns according to the Centers for Disease Control guidelines for patients with known antibioticresistant bacteria. In 2011, ICU staff collected baseline data on the primary outcome of MRSA or VRE acquisition. The ICUs were then pair matched based on baseline MRSA or VRE acquisition rates as a composite outcome. The primary outcome was acquisition of either MRSA or VRE as a composite based on results of ICU admission and discharge surveillance cultures for MRSA and VRE. Secondary outcomes were MRSA and VRE acquisition as 2 separate outcomes, frequency of health care worker visits, hand hygiene compliance, health care-associated infections, and adverse events. Analyses of all outcomes were conducted at the ICU level, followed the intention-to-treat approach, and accounted for the matched-pair design.During the baseline and study periods, 6324 and 19,856 patients were admitted to ICUs, respectively, and 20,646 and 71,595 swabs, respectively, were collected for detection of MRSA and VRE. Compliance with wearing gloves in the intervention ICUs was 86.18% (2787/3234), and compliance with gowns was 85.14% (2750/3230). In the control group, 10.52% of patients were on contact precautions, and for these patients, compliance with staff wearing gloves and gowns was 84.11% (556/661) and 81.21% (536/660), respectively. The intervention ICUs had a decrease in the primary outcome from 21.35 acquisitions per 1000 patient-days (95% confidence interval [CI], in the baseline period to 16.92 acquisitions per 1000 patientdays (95% CI, 14.09-20.28) in the study period. Control ICUs had a decrease from 19.02 acquisitions per 1000 patient-days (95% CI, 14.20-25.49 acquisitions) in the baseline period to 16.29 acquisitions per 1000 patient-days (95% CI,) in the study period. This difference in changes was not statistically significant (difference, −1....

Contact precautions were found to be associated with activities likely to reduce transmission of resistant pathogens, such as fewer visits and better hand hygiene at exit, while exposing patients on contact precautions to less HCW contact, less visitor contact, and potentially other unintended outcomes.

Key Points Question Do practitioners understand the probability of common clinical diagnoses? Findings In this survey study of 553 practitioners performing primary care, respondents overestimated the probability of diagnosis before and after testing. This posttest overestimation was associated with consistent overestimates of pretest probability and overestimates of disease after specific diagnostic test results. Meaning These findings suggest that many practitioners are unaccustomed to using probability in diagnosis and clinical practice. Widespread overestimates of the probability of disease likely contribute to overdiagnosis and overuse.

Background The relationship between common patient characteristics, such as sex and metabolic comorbidities, and mortality from COVID-19 remains incompletely understood. Emerging evidence suggests that metabolic risk factors may also vary by age. This study aimed to determine the association between common patient characteristics and mortality across age-groups among COVID-19 inpatients. Methods We performed a retrospective cohort study of patients discharged from hospitals in the Premier Healthcare Database between April – June 2020. Inpatients were identified using COVID-19 ICD-10-CM diagnosis codes. A priori-defined exposures were sex and present-on-admission hypertension, diabetes, obesity, and interactions between age and these comorbidities. Controlling for additional confounders, we evaluated relationships between these variables and in-hospital mortality in a log-binomial model. Results Among 66,646 (6.5%) admissions with a COVID-19 diagnosis, across 613 U.S. hospitals, 12,388 (18.6%) died in-hospital. In multivariable analysis, male sex was independently associated with 30% higher mortality risk (aRR, 1.30, 95% CI: 1.26 – 1.34). Diabetes without chronic complications was not a risk factor at any age (aRR 1.01, 95% CI: 0.96 – 1.06), and hypertension without chronic complications was only a risk factor in 20-39 year-olds (aRR, 1.68, 95% CI: 1.17 – 2.40). Diabetes with chronic complications, hypertension with chronic complications, and obesity were risk factors in most age-groups, with highest relative risks among 20-39 year-olds (respective aRRs 1.79, 2.33, 1.92; p-values ≤ 0.002). Conclusions Hospitalized men with COVID-19 are at increased risk of death across all ages. Hypertension, diabetes with chronic complications, and obesity demonstrated age-dependent effects, with the highest relative risks among adults aged 20-39.

OBJECTIVE To determine the typical microbial bioburden (overall bacterial and multidrug-resistant organisms [MDROs]) on high-touch healthcare environmental surfaces after routine or terminal cleaning. DESIGN Prospective 2.5-year microbiological survey of large surface areas (>1,000 cm2). SETTING MDRO contact-precaution rooms from 9 acute-care hospitals and 2 long-term care facilities in 4 states. PARTICIPANTS Samples from 166 rooms (113 routine cleaned and 53 terminal cleaned rooms). METHODS Using a standard sponge-wipe sampling protocol, 2 composite samples were collected from each room; a third sample was collected from each Clostridium difficile room. Composite 1 included the TV remote, telephone, call button, and bed rails. Composite 2 included the room door handle, IV pole, and overbed table. Composite 3 included toileting surfaces. Total bacteria and MDROs (ie, methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci [VRE], Acinetobacter baumannii, Klebsiella pneumoniae, and C. difficile) were quantified, confirmed, and tested for drug resistance. RESULTS The mean microbial bioburden and range from routine cleaned room composites were higher (2,700 colony-forming units [CFU]/100 cm2; ≤1-130,000 CFU/100 cm2) than from terminal cleaned room composites (353 CFU/100 cm2; ≤1-4,300 CFU/100 cm2). MDROs were recovered from 34% of routine cleaned room composites (range ≤1-13,000 CFU/100 cm2) and 17% of terminal cleaned room composites (≤1-524 CFU/100 cm2). MDROs were recovered from 40% of rooms; VRE was the most common (19%). CONCLUSIONS This multicenter bioburden summary provides a first step to determining microbial bioburden on healthcare surfaces, which may help provide a basis for developing standards to evaluate cleaning and disinfection as well as a framework for studies using an evidentiary hierarchy for environmental infection control. Infect Control Hosp Epidemiol 2016;1426-1432.

This study examined the effect of services provided through Maryland's Home and Community-Based Services Medicaid waiver for children with autism on several outcomes related to families, specifically family quality of life (FQoL) and employment. The purpose of this study was to assess the impact of the services provided through the Maryland autism waiver on families' perceived quality of life by comparing responses of families receiving waiver services in Maryland with families in the same state who were on the registry (i.e., a waiting list) for waiver services. An invitation letter and Internet-based survey were sent out to 723 waiver recipients and 2,298 families on the wait-list registry by the state's agency administering the waiver program. Some 861 surveys (229 waiver, 632 registry) were returned, yielding an overall response rate of 28.8% (31.6% waiver, 27.5% registry). Both study groups reported lower satisfaction with FQoL and the majority of respondents in both groups reported that having a child with autism affected their employment. However, the findings suggest that families of children with autism who currently receive services through the waiver report higher FQoL than those not receiving services through the waiver. The authors note that there needs to be additional research to fully understand the most effective features of the waiver, including whether and how waiver programs make a difference in families' quality of life, health, and participation in school, work and leisure activities, and the effect of self-determination on these outcomes.

Objective Contact precautions decrease healthcare worker–patient contact and may impact patient satisfaction. To determine the association between contact precautions and patient satisfaction, we used a standardized interview for perceived issues with care. Design Prospective cohort study of inpatients, evaluated at admission and on hospital days 3, 7, and 14 (until discharged). At each point, patients underwent a standardized interview to identify perceived problems with care. After discharge, the standardized interview and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey were administered by telephone. Responses were recorded, transcribed, and coded by 2 physician reviewers. Participants A total of 528 medical or surgical patients not admitted to the intensive care unit. Results A total of 528 patients were included in the primary analysis, of whom 104 (20%) perceived some issue with their care. On multivariable logistic regression, contact precautions were independently associated with a greater number of perceived concerns with care (odds ratio, 2.05 [95% confidence interval, 1.31–3.21]; P < .01), including poor coordination of care (P = .02) and a lack of respect for patient needs and preferences (P = .001). Eighty-eight patients were included in the secondary analysis of HCAHPS. Patients under contact precautions did not have different HCAHPS scores than those not under contact precautions (odds ratio, 1.79 [95% confidence interval, 0.64–5.00]; P = .27). Conclusions Patients under contact precautions were more likely to perceive problems with their care, especially poor coordination of care and a lack of respect for patient preferences.

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