Study Design. Retrospective hospital-registry study. Objective. To characterize the microbial epidemiology of surgical site infection (SSI) in spinal fusion surgery and the burden of resistance to standard surgical antibiotic prophylaxis. Summary of Background Data. SSI persists as a leading complication of spinal fusion surgery despite the growth of enhanced recovery programs and improvements in other measures of surgical quality. Improved understandings of SSI microbiology and common mechanisms of failure for current prevention strategies are required to inform the development of novel approaches to prevention relevant to modern surgical practice. Methods. Spinal fusion cases performed at a single referral center between January 2011 and June 2019 were reviewed and SSI cases meeting National Healthcare Safety Network criteria were identified. Using microbiologic and procedural data from each case, we analyzed the anatomic distribution of pathogens, their differential time to presentation, and correlation with methicillin-resistant Staphylococcus aureus screening results. Susceptibility of isolates cultured from each infection were compared with the spectrum of surgical antibiotic prophylaxis administered during the index procedure on a per-case basis. Susceptibility to alternate prophylactic agents was also modeled. Results. Among 6727 cases, 351 infections occurred within 90 days. An anatomic gradient in the microbiology of SSI was observed across the length of the back, transitioning from cutaneous (gram-positive) flora in the cervical spine to enteric (gram-negative/anaerobic) flora in the lumbosacral region (correlation coefficient 0.94, P < 0.001). The majority (57.5%) of infections were resistant to the prophylaxis administered during the procedure. Cephalosporin-resistant gram-negative infection was common at lumbosacral levels and undetected methicillin-resistance was common at cervical levels. Conclusion. Individualized infection prevention strategies tailored to operative level are needed in spine surgery. Endogenous wound contamination with enteric flora may be a common mechanism of infection in lumbosacral fusion. Novel approaches to prophylaxis and prevention should be prioritized in this population. Level of Evidence: 3

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We report an attempt at automating surveillance for CAUTI. With a high negative predictive value, the electronic tool allows for more efficient CAUTI surveillance and facilitates housewide trending of rates and catheter utilization. This approach should be validated in different patient populations.

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND: Hospital-acquired venous thromboembolism (HA-VTE) is a potentially preventable cause of morbidity and mortality. Despite high rates of venous thromboembolism (VTE) prophylaxis in accordance with an institutional guideline, VTE remains the most common hospital-acquired condition in our institution.

Homelessness has not previously been identified as a risk factor for respiratory syncytial virus (RSV) infection. We conducted an observational study at an urban safety-net hospital in Washington, USA, during 2012–2017. Hospitalized adults with RSV were more likely to be homeless, and several clinical outcome measures were worse with RSV than with influenza.

Shared Hoppers: A Novel Risk Factor for the Transmission of Clostridium difficileTo the Editor-The environment plays a central role in transmission of Clostridium difficile infection (CDI) within hospitals. Surfaces and objects become contaminated with spores when in contact with feces, and these hardy spores may endure for months. Patient placement factors-such as rooming with or residing in a bed previously occupied by a CDI patient-are cited as risk factors for acquisition. 1,2 One geographic feature that may increase risk for CDI is the presence of a shared hopper room in the patient care area. A hopper is a flushable, raised basin with an extendable arm that produces a high-pressure spray when flushed. This rimless basin is used by hospital staff to dispose of waste fluids and wash out receptacles. C. difficile has been isolated from air samples after flushing lidless toilets, leading to contamination of proximate surfaces. 3 Our trauma-surgical intensive care unit (TSICU) historically has had the highest burden of CDI in our facility. The 2010 rate of hospital-acquired CDI for the TSICU was 3.5 cases per 1,000 patient-days compared with other intensive care units (range, 1.5-2.4 cases per 1,000 patient-days). Despite implementation of infection prevention measures-including hand hygiene with soap and water, a nurse-driven early CDI testing strategy, empirical contact precautions while awaiting test results, environmental cleaning with hypochlorite (bleach) solution, and cleaning audits-the high rates persisted. During the spring of 2011, we observed a cluster of CDI cases in our TSICU. Two patients acquired CDI while housed in a double room adjacent to a patient in contact precautions with CDI in a private room. The 2 rooms were joined by a shared hopper room. Neighboring patients who did not share the hopper, however, did not become infected. We hypothesized that transmission occurred by healthcare worker contamination of hands, uniform, and fomites via splashing and droplet aerosol during hopper flushing and use of the sprayer. We sought to examine patient and environmental risk factors for CDI acquisition.We conducted a case-control study at Harborview Medical Center, a 413-bed, level 1 trauma and burn center with a 24-bed TSICU. The study spanned the 12-month period from December 15, 2010, through December 14, 2011. Generally, cases were defined as those with new onset diarrhea and a positive polymerase chain reaction (PCR) test for C. difficile toxin B greater than 48 hours from TSICU admission. Patients with a recent acute or long-term care hospital stay were excluded to minimize misclassification of exposure. The control group had a TSICU stay of greater than 36 hours and no positive C. difficile PCR test for at least 30 days after discharge from the TSICU. Approximately 3 concurrent controls were randomly selected within 1 week of admission for each case.Electronic health records were reviewed for a history of CDI within the past 3 years. Potential risk factors for acquisition were determined for...

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