We assessed the appropriateness of intravenous antimicrobial starts (IVASs) in Philadelphia County hemodialysis facilities using only National Healthcare Safety Network data. We classified 57.5% of IVASs as inappropriate. These findings warrant further investigation into the determinants of inappropriate IVASs in hemodialysis facilities to enhance antimicrobial stewardship.
We report a fatal infection in a 65-year-old immunocompromised male patient caused by pan-triazole–resistant Aspergillus fumigatus containing a TR 34 /L98H genetic mutation linked to agricultural fungicide use. Clinical and environmental surveillance of triazole-resistant A. fumigatus is needed in the United States to prevent spread and guide healthcare and agricultural practices.
Background: Most dental clinics lack resources and oversight related to infection prevention and control (IPC) practices. Few dental clinics undergo inspections by regulatory authorities unless the state licensing authorities receive a specific complaint. Many states, including Pennsylvania, do not have continuing IPC education requirements for dental providers. In 2018–2019, the Philadelphia Department of Public Health (PDPH) received and responded to multiple complaints and concerns related to IPC practices at dental clinics. Complaints were investigated in collaboration with the Pennsylvania Department of State (PADOS). Methods: Unannounced site visits were conducted at 7 Philadelphia dental clinics from December 2018 through September 2019 as part of the public health responses. Clinic evaluations and observations by PDPH certified infection preventionists focused on (1) IPC policies and procedures, (2) staff IPC training, (3) hand hygiene, (4) personal protective equipment, (5) instrument reprocessing and sterilization, (6) injection safety, and (7) environmental cleaning and disinfection. The CDC and the Organization of Safety, Antisepsis and Prevention (OSAP) checklists were adapted for this purpose. Results: Most dental practices we visited were small, unaffiliated, owner-operated clinics. The most common gaps we identified were associated with instrument reprocessing and sterilization practices, including inadequate separation between clean and dirty work areas, limited space and availability of sinks, inappropriate use of glutaraldehyde products for instrument cleaning (n = 3, 43%), extended reuse of cleaning brushes (n = 5, 71%), sterilization or storage of sterilized instruments without appropriate packaging (n = 2, 29%), lack of spore testing or reviewing results (n = 2, 29%), and lack of documentation of sterilizer run cycles and maintenance (n = 7, 100%). Additionally, most clinics did not have well-developed IPC policies and procedures, and staff IPC trainings were neither documented nor conducted annually. Alcohol-based hand sanitizer was often not available at the point of use. Conclusions: In Philadelphia, dental clinics often lacked IPC support and oversight. Lapses across multiple key IPC domains were common. These findings suggest that public health may have a role in providing IPC support to unaffiliated dental clinics. Licensing entities can also serve a role in improving IPC practices by more widely mandating continuing IPC education as part of the dental license renewal process.Funding: NoneDisclosures: None
Background: Carbapenem-resistant Enterobacteriaceae (CRE) are an important cause of healthcare-associated infections (HAIs) in human hospitals. The Philadelphia Department of Public Health (PDPH) made CRE reportable in April 2018. In May 2019, the Matthew J. Ryan Veterinary Hospital (MJRVH) reported an NDM-5 Escherichia coli cluster in companion animals to the PDPH. In total, 15 infected animals (14 dogs and 1 cat) were reported between July 2018 and June 2019, with no new infections after June 2019. Limited literature is available on the prevalence of CRE in companion animals, and recommendations for dealing with CRE infections currently target human healthcare settings. Methods: A collaborative containment response included assessing interspecies transmission to veterinary staff and a comprehensive evaluation of the infection control program at MJRVH. MJRVH notified all owners of affected animals verbally and via notification letters with PDPH recommendations for CRE colonization screening of high-risk individuals. CRE screening of exposed high-risk employees was conducted by the University of Pennsylvania Occupational Health service and PDPH. Human rectal swabs were analyzed at the Antibiotic Resistance Laboratory Network (ARLN) Maryland Laboratory. PDPH were invited to conduct an onsite infection control assessment and to suggest improvements. Results: No pet owners self-identified in high-risk groups to be screened. In total, 10 high-risk staff were screened, and no colonized individuals were detected. Recommendations made by the PDPH to MJRVH included improvement of infection prevention and control policies (eg, consolidation of the infection control manual and identification of lead staff member), improvement in hand hygiene (HH) compliance (eg, increasing amount of HH supplies), improvement of environment of care (eg, decluttering and evaluation of mulched animal relief area), and improvement of respiratory care processes (eg, standardization of care policies). MJRVH made substantial improvements across recommendation areas including revision of infection control manual, creation of a full-time infection preventionist position, individual alcohol hand sanitizers for patient cages, and environmental decluttering and decontamination. PDPH and MJRVH maintained frequent communication about infection control improvements. Conclusions: No positive transmission to high-risk staff members suggest that, like in human healthcare facilities, transmission of CRE to caretakers may not be a common event. Stronger communication and collaboration is required from Departments of Public Health (DPH) to the veterinary profession regarding the reporting requirements of emerging pathogens such as CRE. Veterinary facilities should view DPH as a valuable resource for recommendations to fill in gaps that exist in infection control “best practices,” particularly for novel pathogens in veterinary settings.Funding: NoneDisclosures: Jane M. Gould reports that her spouse receives salary from Incyte.
Background: The Occupational Safety and Health Administration (OSHA) Respiratory Protection standard (29 CFR 1910.134) states that it is an employer’s responsibility to establish and maintain a respiratory protection program when a respirator is necessary to protect the health of employees, including annual assessment of adequate respirator fit. Prior to the COVID-19 pandemic, N95 respirators were rarely used in Philadelphia skilled-nursing facilities (SNFs), and many facilities did not have programs in place or materials to fit test their staff. Methods: The Philadelphia Department of Public Health’s (PDPH) Healthcare Associated Infections/Antimicrobial Resistance (HAI/AR) Program designed and pilot-tested 1.5-hour “train-the-trainer” sessions on OSHA-compliant fit-testing requirements and qualitative procedures. This training was offered to all 47 SNFs beginning May 2021. Training covered the role N95 respirators play in healthcare, proper donning and doffing, OSHA training requirements, medical clearances, record keeping, fit-testing procedure, and demonstrated competency to perform fit testing. Resources that were provided after training included templates of a respiratory protection policy for SNFs, a fit-test record, the OSHA medical clearance form, and a competency checklist. This bundle was designed to help SNFs establish self-sustaining respiratory protection programs. Post-training evaluations were administered on a 6-point Likert scale as well as qualitative, open-ended questions to evaluate the overall quality and effectiveness of the training session. Results: In total, 50 employees (clinical and nonclinical) from 13 Philadelphia SNFs received N95 fit-test training from June through December 2021. The average rating for the training overall was very high (5.9 of 6 points). On average, participants strongly agreed that content presented was directly applicable to their work (5.9 of 6 points), and most strongly agreed that information they learned would alter practices and procedures (5.79 of 6 points). When asked qualitatively what the participant would do differently in practice as a result of the training, the most frequent responses were fit test staff (58%) and educate staff on proper N95 use (60%). Conclusions: The PDPH HAI/AR program created a successful pilot fit-test training program for SNFs, demonstrated by program enrollment and high ratings by participants. This relatively low-cost intervention has provided tools to enhance respiratory protection during the COVID-19 pandemic and has increases the capacity of SNFs to provide essential services for their staff and residents. The PDPH will continue to offer these training sessions to SNFs, with plans to expand to other care settings, such as inpatient behavioral health facilities, outpatient clinics, and emergency medical services.Funding: Funded by the CDC ELC Project FirstlineDisclosures: None
Objective: Gastroenteritis causes significant morbidity and mortality in long-term care facility (LTCF) residents, a growing population within the United States. We set out to better understand gastroenteritis outbreaks in LTCF by identifying outbreak and facility characteristics associated with outbreak incidence as well as outbreak duration and size. Design: We conducted a retrospective cross-sectional study on LTCFs in Philadelphia County from 2009 to 2018. Outbreak characteristics and interventions were extracted from Philadelphia Department of Public Health (PDPH) database and quality data on all LTCFs was extracted from Centers for Medicare and Medicaid Services Nursing Home Compare database. Results: We identified 121 gastroenteritis outbreaks in 49 facilities. Numbers of affected patients ranged from 2 to 211 patients (median patient illness rate, 17%). Staff were reported ill in 94 outbreaks (median staff illness rate, 5%). Outbreak facilities were associated with higher occupancy rates (91% vs 88%; P = .033) and total bed numbers (176 vs 122; P = .071) compared to nonoutbreak facilities. Higher rates of staff illness were associated with prolonged outbreaks (13% vs 4%; P < .001) and higher patient illness rates (9% vs 4%; P = .012). Prolonged outbreaks were associated with lower frequency of cohorting for outbreak management (13% vs 41%; P = .046). Conclusion: This study is the largest published analysis of gastroenteritis outbreaks in LTCFs. Facility characteristics and staff disease activity were associated with more severe outbreaks. Heightened surveillance for gastrointestinal symptoms among staff and increased use of cohorting might reduce the risk of prolonged gastroenteritis outbreaks in LTCF.
Background: Gastroenteritis causes significant morbidity and mortality in long-term care facility (LTCF) residents, a growing population within the United States. Methods: We conducted a retrospective cross-sectional study in LTCFs in Philadelphia County from 2009 to 2018. Outbreak characteristics and interventions were extracted from Philadelphia Department of Public Health’s (PDPH) database, and quality data on all LTCFs was extracted from the CMS Nursing Home Compare database. Results: We identified 121 gastroenteritis outbreaks in 49 facilities. Numbers of affected patients ranged from 2 to 211 patients (median patient attack rate, 17%). Staff were reported ill in 94 outbreaks (median staff attack rate, 5%). Outbreak facilities were associated with higher occupancy rates (91% vs 88%; P = .033) and total bed numbers (176 vs 122; P = .071) when compared to nonoutbreak facilities. Higher rates of staff illness were associated with prolonged outbreaks (13% vs 4%; P < .001) and higher patient illness rates (9% vs 4%; P = .012). Prolonged outbreaks were associated with lower frequency of cohorting for outbreak management (13% vs 41%; P = .046). Conclusions: This study is the largest published analysis of gastroenteritis outbreaks in LTCFs. Facility characteristics and staff disease 20 activity were associated with more severe outbreaks. Heightened surveillance for gastrointestinal symptoms among staff and increased 21 use of cohorting might reduce the risk of prolonged gastroenteritis outbreaks in LTCF.Funding: NoneDisclosures: None
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