Publications by authors named "Jeanmarie Mayer"

39 Publications

Efficient and effective single-step screening of individual samples for SARS-CoV-2 RNA using multi-dimensional pooling and Bayesian inference.

J R Soc Interface 2021 06 16;18(179):20210155. Epub 2021 Jun 16.

Department of Chemistry, University of Utah, Salt Lake City, UT, USA.

Rapid and widespread implementation of infectious disease surveillance is a critical component in the response to novel health threats. Molecular assays are the preferred method to detect a broad range of viral pathogens with high sensitivity and specificity. The implementation of molecular assay testing in a rapidly evolving public health emergency, such as the ongoing COVID-19 pandemic, can be hindered by resource availability or technical constraints. We present a screening strategy that is easily scaled up to support a sustained large volume of testing over long periods of time. This non-adaptive pooled-sample screening protocol employs Bayesian inference to yield a reportable outcome for each individual sample in a single testing step (no confirmation of positive results required). The proposed method is validated using clinical specimens tested using a real-time reverse transcription polymerase chain reaction test for SARS-CoV-2. This screening protocol has substantial advantages for its implementation, including higher sample throughput, faster time to results, no need to retrieve previously screened samples from storage to undergo retesting, and excellent performance of the algorithm's sensitivity and specificity compared with the individual test's metrics.
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http://dx.doi.org/10.1098/rsif.2021.0155DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8205536PMC
June 2021

Interim Estimates of Vaccine Effectiveness of Pfizer-BioNTech and Moderna COVID-19 Vaccines Among Health Care Personnel - 33 U.S. Sites, January-March 2021.

MMWR Morb Mortal Wkly Rep 2021 May 21;70(20):753-758. Epub 2021 May 21.

Throughout the COVID-19 pandemic, health care personnel (HCP) have been at high risk for exposure to SARS-CoV-2, the virus that causes COVID-19, through patient interactions and community exposure (1). The Advisory Committee on Immunization Practices recommended prioritization of HCP for COVID-19 vaccination to maintain provision of critical services and reduce spread of infection in health care settings (2). Early distribution of two mRNA COVID-19 vaccines (Pfizer-BioNTech and Moderna) to HCP allowed assessment of the effectiveness of these vaccines in a real-world setting. A test-negative case-control study is underway to evaluate mRNA COVID-19 vaccine effectiveness (VE) against symptomatic illness among HCP at 33 U.S. sites across 25 U.S. states. Interim analyses indicated that the VE of a single dose (measured 14 days after the first dose through 6 days after the second dose) was 82% (95% confidence interval [CI] = 74%-87%), adjusted for age, race/ethnicity, and underlying medical conditions. The adjusted VE of 2 doses (measured ≥7 days after the second dose) was 94% (95% CI = 87%-97%). VE of partial (1-dose) and complete (2-dose) vaccination in this population is comparable to that reported from clinical trials and recent observational studies, supporting the effectiveness of mRNA COVID-19 vaccines against symptomatic disease in adults, with strong 2-dose protection.
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http://dx.doi.org/10.15585/mmwr.mm7020e2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8136422PMC
May 2021

Environmental Contamination of Contact Precaution and Non-Contact Precaution Patient Rooms in Six Acute Care Facilities.

Clin Infect Dis 2021 01;72(Suppl 1):S8-S16

Division of Epidemiology, University of Utah, Salt Lake City, Utah, USA.

Background: Environmental contamination is an important source of hospital multidrug-resistant organism (MDRO) transmission. Factors such as patient MDRO contact precautions (CP) status, patient proximity to surfaces, and unit type likely influence MDRO contamination and bacterial bioburden levels on patient room surfaces. Identifying factors associated with environmental contamination in patient rooms and on shared unit surfaces could help identify important environmental MDRO transmission routes.

Methods: Surfaces were sampled from MDRO CP and non-CP rooms, nursing stations, and mobile equipment in acute care, intensive care, and transplant units within 6 acute care hospitals using a convenience sampling approach blinded to cleaning events. Precaution rooms had patients with clinical or surveillance tests positive for methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, carbapenem-resistant Enterobacteriaceae or Acinetobacter within the previous 6 months, or Clostridioides difficile toxin within the past 30 days. Rooms not meeting this definition were considered non-CP rooms. Samples were cultured for the above MDROs and total bioburden.

Results: Overall, an estimated 13% of rooms were contaminated with at least 1 MDRO. MDROs were detected more frequently in CP rooms (32% of 209 room-sample events) than non-CP rooms (12% of 234 room-sample events). Surface bioburden did not differ significantly between CP and non-CP rooms or MDRO-positive and MDRO-negative rooms.

Conclusions: CP room surfaces are contaminated more frequently than non-CP room surfaces; however, contamination of non-CP room surfaces is not uncommon and may be an important reservoir for ongoing MDRO transmission. MDRO contamination of non-CP rooms may indicate asymptomatic patient MDRO carriage, inadequate terminal cleaning, or cross-contamination of room surfaces via healthcare personnel hands.
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http://dx.doi.org/10.1093/cid/ciaa1602DOI Listing
January 2021

Shedding of multidrug-resistant gram-negative bacilli by colonized patients during procedures and patient care activities.

Am J Infect Control 2020 11 6;48(11):1336-1340. Epub 2020 Jun 6.

Geriatric Research, Education and Clinical Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH; Case Western Reserve University School of Medicine, Cleveland, OH. Electronic address:

Background: Medical procedures and patient care activities may facilitate environmental shedding of health care-associated pathogens.

Methods: We conducted a cohort study of hospitalized patients in contact precautions for carriage of extended-spectrum beta-lactamase (ESBL)-producing gram-negative bacilli (N = 38) or carbapenem-resistant gram-negative bacilli (CR-GNB) (N = 22) to determine the frequency of environmental shedding during procedures and care activities. Perirectal, wound, and skin were cultured for ESBL-producing and CR-GNB. High-touch surfaces and portable equipment were disinfected before and cultured after procedures; control cultures were collected in the absence of procedures.

Results: Of 60 patients enrolled, 34 (57%) had positive perirectal and/or skin or wound cultures. For these 34 patients, 15 (44%) shed their colonizing organism to surfaces during 1 or more procedures. Patients with shedding had significantly higher concentrations of the pathogens recovered from perirectal swabs than those with no shedding (mean, 3.5 vs 2.2 log colony-forming units per swab; P < .01). Environmental shedding occurred more frequently during procedures and care activities than in the absence of a procedure (21 of 117, 18% vs 1 of 61, 2%; P < .01), and 6 of 56 (10%) portable devices used for procedures became contaminated.

Conclusions: Environmental shedding of antibiotic-resistant gram-negative bacilli occurs frequently during medical procedures and patient care activities. Decontamination of surfaces and equipment and approaches that reduce the burden of carriage could reduce the risk for dissemination.
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http://dx.doi.org/10.1016/j.ajic.2020.06.004DOI Listing
November 2020

Prevalence of IgG antibodies to SARS-CoV-2 among emergency department employees.

Am J Emerg Med 2020 12 3;38(12):2752. Epub 2020 May 3.

University of Utah School of Medicine, Salt Lake City, UT, United States of America.

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http://dx.doi.org/10.1016/j.ajem.2020.04.076DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7252005PMC
December 2020

Estimating the Incidence of Influenza at the State Level - Utah, 2016-17 and 2017-18 Influenza Seasons.

MMWR Morb Mortal Wkly Rep 2019 Dec 20;68(50):1158-1161. Epub 2019 Dec 20.

The 2017-18 U.S. influenza season was notable for its high severity, with approximately 45 million illnesses and 810,000 influenza-associated hospitalizations throughout the United States (1). The purpose of the investigation reported here was to create a state-level estimate of the number of persons in Utah who became ill with influenza disease during this severe national seasonal influenza epidemic and to create a sustainable system for making timely updates in future influenza seasons. Knowing the extent of influenza-associated illness can help public health officials, policymakers, and clinicians tailor influenza messaging, planning, and responses for seasonal influenza epidemics or during pandemics. Using national methods and existing influenza surveillance and testing data, the influenza burden (number of influenza illnesses, medical visits for influenza, and influenza-associated hospitalizations) in Utah during the 2016-17 and 2017-18 influenza seasons was estimated. During the 2016-17 season, an estimated 265,000 symptomatic illnesses affecting 9% of Utah residents occurred, resulting in 125,000 medically attended illnesses and 2,700 hospitalizations. During the 2017-18 season, an estimated 338,000 symptomatic illnesses affecting 11% of Utah residents occurred, resulting in 160,000 medically attended illnesses and 3,900 hospitalizations. Other state or county health departments could adapt similar methods in their jurisdictions to estimate the burden of influenza locally and support prompt public health activities.
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http://dx.doi.org/10.15585/mmwr.mm6850a2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6936161PMC
December 2019

Reinforcement of an infection control bundle targeting prevention practices for Clostridioides difficile in Veterans Health Administration nursing homes.

Am J Infect Control 2020 06 5;48(6):626-632. Epub 2019 Dec 5.

Edward Hines Jr Veterans Affairs Hospital, Hines, IL; Loyola University, Stritch School of Medicine, Hines, IL.

Background: Clostridioides difficile infection (CDI) causes significant morbidity in nursing home residents. Our aim was to describe adherence to a bundled CDI prevention initiative, which had previously been deployed nationwide in Veterans Health Administration (VA) long-term care facilities (LTCFs), and to improve compliance with reinforcement.

Methods: A multicenter pre- and post-reinforcement of the VA bundle consisting of environmental management, hand hygiene, and contact precautions was conducted in 6 VA LTCFs. A campaign to reinforce VA bundle components, as well as to promote select antimicrobial stewardship recommendations and contact precautions for 30 days, was employed. Hand hygiene, antimicrobial usage, and environmental contamination, before and after bundle reinforcement, were assessed.

Results: All LTCFs reported following the guidelines for cleaning and contact precautions until diarrhea resolution pre-reinforcement. Environmental specimens rarely yielded C difficile pre- or post-reinforcement. Proper hand hygiene across all facilities did not change with reinforcement (pre 52.51%, post 52.18%), nor did antimicrobial use (pre 87-197 vs. post 84-245 antibiotic days per 1,000 resident-days). LTCFs found it challenging to maintain prolonged contact precautions.

Discussion: Variation in infection prevention and antimicrobial prescribing practices across LTCFs were identified and lessons learned.

Conclusions: Introducing bundled interventions in LTCFs is challenging, given the available resources, and may be more successful with fewer components and more intensive execution with feedback.
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http://dx.doi.org/10.1016/j.ajic.2019.09.019DOI Listing
June 2020

Environmental Contamination with Species in Multiple Hospitals Including a Tertiary Care Hospital with a Outbreak.

Pathog Immun 2019 28;4(2):260-270. Epub 2019 Oct 28.

Geriatric Research, Education, and Clinical Center; Louis Stokes Cleveland VA Medical; Cleveland, Ohio.

Background: Environmental sources have been implicated as a potential source for exogenous acquisition of species, particularly the emerging multidrug-resistant . However, limited information is available on environmental reservoirs of species in healthcare facilities.

Methods: During a 6-month period, cultures for species were collected from high-touch surfaces in patient rooms and from portable equipment in 6 US acute care hospitals in 4 states. Additional cultures were collected from sink drains and floors in one of the hospitals and from high-touch surfaces, portable equipment, and sink drains in a hospital experiencing an outbreak due to species were identified using matrix-assisted laser desorption/ionization time-of-flight mass spectometry.

Results: species were recovered from patient rooms in 4 of the 6 hospitals. Seven of 147 patient room cultures (4.8%) and 1 of 57 (1.8%) portable equipment cultures were positive, with the most common species being For the hospital where additional sites were sampled, species were recovered from 8 of 22 (36.4%) hospital room floors and 4 of 17 (23.5%) sink drains. In the facility with a outbreak, species were frequently recovered from sink drains (20.7%) and high-touch surfaces (15.4%), but recovery of was uncommon (3.8% of high-touch surfaces, 3.4% of sink drains, and 0% of portable equipment) and only present in rooms that currently or recently housed a patient with .

Conclusion: species often contaminate surfaces in hospitals and may be particularly common on floors and in sink drains. However, contamination was uncommon in a facility experiencing an outbreak, suggesting that current cleaning and disinfection practices can be effective in minimizing environmental contamination.
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http://dx.doi.org/10.20411/pai.v4i2.291DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6827507PMC
October 2019

A qualitative study of factors affecting personal protective equipment use among health care personnel.

Am J Infect Control 2020 04 11;48(4):410-415. Epub 2019 Oct 11.

VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI; Department of Internal Medicine, University of Michigan, Ann Arbor, MI.

Background: Health care personnel (HCP) use of personal protective equipment (PPE) reduces infectious disease transmission. However, PPE compliance remains low. The objective of this study was to better understand how HCP perceptions factor into PPE decision making as well as how organizational processes and the environment impact behavior.

Methods: This qualitative study used observation and focus groups at 2 medical centers. Data were analyzed using thematic analysis.

Results: The decision to use PPE and to follow precaution practices was influenced by risk perception as well as organizational and environmental factors. Perceived risk, related to certain organisms and work tasks, was considered by HCP when deciding to use PPE. Organizational processes, such as policies that were not applied uniformly, and environmental factors, such as clean versus contaminated space, also played a role in HCP PPE use.

Discussion: Because HCP seemed focused on organisms and work tasks, education on specific organisms and helping HCP think through their workflow may be more effective in conveying the importance of PPE in reducing transmission. Additionally, isolation practices should be compared across disciplines to ensure they complement, rather than contradict, one another. Assessment of the environment may help protect HCP and patients from infectious organisms.

Conclusion: Preventing the spread of infectious organisms should not depend solely on PPE use, but should also be recognized as an organizational responsibility.
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http://dx.doi.org/10.1016/j.ajic.2019.08.031DOI Listing
April 2020

Evaluation of a Redesigned Personal Protective Equipment Gown.

Clin Infect Dis 2019 09;69(Suppl 3):S199-S205

Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City.

Background: In healthcare, the goal of personal protective equipment (PPE) is to protect healthcare personnel (HCP) and patients from body fluids and infectious organisms via contact, droplet, or airborne transmission. The critical importance of using PPE properly is highlighted by 2 potentially fatal viral infections, severe acute respiratory syndrome-associated coronavirus and Ebola virus, where HCP became infected while caring for patients due to errors in the use of PPE. However, PPE in dealing with less dangerous, but highly infectious organisms is important as well. This work proposes a framework to test and evaluate PPE with a focus on gown design.

Methods: An observational study identified issues with potential for contamination related to gown use. After redesigning the existing gown, a high-fidelity patient simulator study with 40 HCP as participants evaluated the gown redesign using 2 commonly performed tasks. Variables of interest were nonadherence to procedural standards, use problems with the gown during task performance, and usability and cognitive task load ratings of the standard and redesigned gowns.

Results: While no differences were found in terms of nonadherence and use problems between the current and the redesigned gown, differences in usability and task load ratings suggested that the redesigned gown is perceived more favorably by HCP.

Conclusions: This work proposes a framework to guide the evaluation of PPE. The results suggest that the current design of the PPE gown can be improved in usability and user satisfaction. Although our data did not find an increase in adherence to protocol when using the redesigned gown, it is likely that higher usability and lower task load could result in higher adherence over longer periods of use.
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http://dx.doi.org/10.1093/cid/ciz520DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6761366PMC
September 2019

Understanding Workflow and Personal Protective Equipment Challenges Across Different Healthcare Personnel Roles.

Clin Infect Dis 2019 09;69(Suppl 3):S185-S191

Veterans Affairs Ann Arbor Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor.

Background: Hospitals use standard and transmission-based precautions, including personal protective equipment (PPE), to prevent the spread of infectious organisms. However, little attention has been paid to the potentially unique challenges of various healthcare personnel (HCP) in following precaution practices.

Methods: From September through December 2016, 5 physicians, 5 nurses, and 4 physical therapists were shadowed for 1 hour 30 minutes to 3 hours 15 minutes at an academic medical center. Observers documented activities using unstructured field notes. Focus groups were conducted to better understand HCP perspectives about precautions and PPE-related challenges. Data were analyzed by comparing workflow and challenges (observed and stated) in precaution practices across HCP roles.

Results: Precaution patients were interspersed throughout physician rounds, which covered a broad geographic range throughout the hospital. Patient encounters were generally brief, and appropriate use of gowns and cleaning of personal stethoscopes varied among observed physicians. Nurses were unit based and frequently entered/exited rooms. Frustration with donning/doffing was especially apparent when needing supplies while in a precaution room, which nurses acknowledged was a time when practice lapses could occur. The observed physical therapists worked in one geographic location, spent extended periods of time with patients, and noted that given their close physical contact with patients, gowns do not fully protect them.

Conclusions: Movement patterns, time with patients, care activities, and equipment use varied across HCP, leading to a diverse set of challenges in following precaution practices and PPE use. Attention to these differences among HCP is important for understanding and developing effective strategies to prevent the potential spread of infectious organisms.
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http://dx.doi.org/10.1093/cid/ciz527DOI Listing
September 2019

Effectiveness of a multisite personal protective equipment (PPE)-free zone intervention in acute care.

Infect Control Hosp Epidemiol 2019 07;40(7):761-766

Division of Epidemiology, Department of Internal Medicine,University of Utah School of Medicine, Salt Lake City,Utah.

Objective: Determine the effectiveness of a personal protective equipment (PPE)-free zone intervention on healthcare personnel (HCP) entry hand hygiene (HH) and PPE donning compliance in rooms of patients in contact precautions.

Design: Quasi-experimental, multicenter intervention, before-and-after study with concurrent controls.

Setting: All patient rooms on contact precautions on 16 units (5 medical-surgical, 6 intensive care, 5 specialty care units) at 3 acute-care facilities (2 academic medical centers, 1 Veterans Affairs hospital). Observations of PPE donning and entry HH compliance by HCP were conducted during both study phases. Surveys of HCP perceptions of the PPE-free zone were distributed in both study phases.

Intervention: A PPE-free zone, where a low-risk area inside door thresholds of contact precautions rooms was demarcated by red tape on the floor. Inside this area, HCP were not required to wear PPE.

Results: We observed 3,970 room entries. HH compliance did not change between study phases among intervention units (relative risk [RR], 0.92; P = .29) and declined in control units (RR, 0.70; P = .005); however, the PPE-free zone did not significantly affect compliance (P = .07). The PPE-free zone effect on HH was significant only for rooms on enteric precautions (P = .008). PPE use was not significantly different before versus after the intervention (P = .15). HCP perceived the zone positively; 65% agreed that it facilitated communication and 66.8% agreed that it permitted checking on patients more frequently.

Conclusions: HCP viewed the PPE-free zone favorably and it did not adversely affect PPE or HH compliance. Future infection prevention interventions should consider the complex sociotechnical system factors influencing behavior change.
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http://dx.doi.org/10.1017/ice.2019.111DOI Listing
July 2019

Frequent and unexpected deviations from personal protective equipment guidelines increase contamination risks.

Am J Infect Control 2019 09 24;47(9):1146-1147. Epub 2019 Apr 24.

IDEAS Center, Veterans Affairs Healthcare System, Salt Lake City, UT; Department of Psychology, University of Utah, Salt Lake City, UT. Electronic address:

Personal protective equipment (PPE) training aims to reinforce the Centers for Disease Control and Prevention guidelines for donning and doffing; however, many health care and ancillary personnel use non-guideline methods to don and doff their PPE gowns and gloves. We found that hospital personnel commonly deviated from the guidelines, increasing the likelihood of self-contamination. Furthermore, securing the gown ties inappropriately was an especially common problem that consequently increased doffing missteps.
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http://dx.doi.org/10.1016/j.ajic.2019.03.013DOI Listing
September 2019

Human Factors Engineering Contributions to Infection Prevention and Control.

Hum Factors 2019 08 18;61(5):693-701. Epub 2019 Mar 18.

University of Utah, Salt Lake City, USA.

Objective: This article provides a review of areas that present significant challenges in infection prevention and control and describes human factors engineering (HFE) approaches that have been applied successfully to these areas. In addition, implications and recommendations for HFE use in future research are discussed.

Background: Infection prevention and control aims to prevent patients and health care personnel from acquiring preventable infections in healthcare. Effective infection control practices of healthcare-associated infections have recently become even more critical with the emergence of life-threatening infections. HFE could benefit infection prevention and control in addressing older and more recent challenges, but uptake has been limited.

Method/results: This literature review is an integration and synthesis of recently published research that describes HFE-based approaches in infection prevention and control to address the challenges for three specific topics. The results of the review suggests that HFE is in a position to support work in infection prevention and control and improve overall healthcare safety.

Conclusion: HFE provides conceptual frameworks and methods that have significant potential to improve infection prevention and control.

Application: The work reviewed can provide potential solutions for current infection prevention and control challenges by applying HFE based recommendations.
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http://dx.doi.org/10.1177/0018720819833214DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7207010PMC
August 2019

Shedding of methicillin-resistant Staphylococcus aureus by colonized patients during procedures and patient care activities.

Infect Control Hosp Epidemiol 2019 03 19;40(3):328-332. Epub 2019 Feb 19.

Geriatric Research, Education and Clinical Center, Louis Stokes Cleveland VA Medical Center,Cleveland, Ohio.

Objective: Medical procedures and patient care activities may facilitate environmental dissemination of healthcare-associated pathogens such as methicillin-resistant Staphylococcus aureus (MRSA).

Design: Observational cohort study of MRSA-colonized patients to determine the frequency of and risk factors for environmental shedding of MRSA during procedures and care activities in carriers with positive nares and/or wound cultures. Bivariate analyses were performed to identify factors associated with environmental shedding.

Setting: A Veterans Affairs hospital.

Participants: This study included 75 patients in contact precautions for MRSA colonization or infection.

Results: Of 75 patients in contact precautions for MRSA, 55 (73%) had MRSA in nares and/or wounds and 25 (33%) had positive skin cultures. For the 52 patients with MRSA in nares and/or wounds and at least 1 observed procedure, environmental shedding of MRSA occurred more frequently during procedures and care activities than in the absence of a procedure (59 of 138, 43% vs 8 of 83, 10%; P 0.9 m from the patient (52 of 138, 38% vs 25 of 138, 18%; P = .0004). Contamination occurred frequently on surfaces touched by personnel (12 of 38, 32%) and on portable equipment used for procedures (25 of 101, 25%). By bivariate analysis, the presence of a wound with MRSA was associated with shedding (17 of 29, 59% versus 6 of 23, 26%; P = .04).

Conclusions: Environmental shedding of MRSA occurs frequently during medical procedures and patient care activities. There is a need for effective strategies to disinfect surfaces and equipment after procedures.
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http://dx.doi.org/10.1017/ice.2018.342DOI Listing
March 2019

Forming a successful public health collaborative: A qualitative study.

Am J Infect Control 2019 06 21;47(6):628-632. Epub 2018 Dec 21.

Department of Internal Medicine, University of Utah Health, Salt Lake City, UT.

Background: Coordinated approaches are needed to optimally control the spread of resistant organisms across facilities that share patients. Our goal was to understand social tensions that may inhibit public health-led community partnerships and to identify factors for success.

Methods: A collaborative to control transmission of multidrug-resistant organisms (MDROs) was formed in Utah following a regional outbreak, with members from public health, hospitals, laboratories, and transport services. We conducted and qualitatively analyzed 3 focus groups among collaborative stakeholders to discuss their experiences.

Results: Via 3 focus groups and additional interviews, we found the collaborative made institutional tensions between stakeholders explicit. We identified 4 factors that facilitated the ability to overcome institutional tensions: public health leadership to establish a safe space, creation of cross-institutional group identity with mutual respect and support, standardized communication, and group cohesiveness through shared mental models of interdependencies.

Discussion: Stakeholders' concerns regarding being blamed for MDRO transmission versus contributing to shared health care community MDRO control efforts resembled a "prisoner's dilemma." Four social components mitigated tensions and facilitated cooperation in this public health-led collaborative.

Conclusions: This study identified strategies that public health-led coordinated approaches can use to facilitate cooperation.
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http://dx.doi.org/10.1016/j.ajic.2018.10.015DOI Listing
June 2019

How Clean Is the Linen at My Hospital? The Mucorales on Unclean Linen Discovery Study of Large United States Transplant and Cancer Centers.

Clin Infect Dis 2019 02;68(5):850-853

University of Pittsburgh School of Medicine, Pennsylvania.

Mucormycosis outbreaks have been linked to contaminated linen. We performed fungal cultures on freshly-laundered linens at 15 transplant and cancer hospitals. At 33% of hospitals, the linens were visibly unclean. At 20%, Mucorales were recovered from >10% of linens. Studies are needed to understand the clinical significance of our findings.
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http://dx.doi.org/10.1093/cid/ciy669DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6765054PMC
February 2019

Identification and Characterization of Failures in Infectious Agent Transmission Precaution Practices in Hospitals: A Qualitative Study.

JAMA Intern Med 2018 08;178(8):1016-1057

Department of Internal Medicine, University of Utah, Salt Lake City.

Importance: Using personal protective equipment (PPE) and transmission-based precautions are primary strategies for reducing the transmission of infectious agents.

Objective: To identify and characterize failures in transmission-based precautions, including PPE use, by health care personnel that could result in self-contamination or transmission during routine, everyday hospital care.

Design, Setting, And Participants: This qualitative study involved direct observation inside and outside patient rooms on clinical units from March 1, 2016, to November 30, 2016. Observations occurred in the medical and/or surgical units and intensive care units at an academic medical center and a Veterans Affairs hospital, as well as the emergency department of the university hospital. Trained observers recorded extensive field notes while personnel provided care for patients in precautions for a pathogen transmitted through contact (eg, Clostridium difficile, methicillin-resistant Staphylococcus aureus) or respiratory droplet (eg, influenza). Specific occurrences involving potential personnel self-contamination were identified through a directed content analysis. These occurrences were further categorized, using a human factors model of human error, as active failures, such as violations, mistakes, or slips.

Main Outcomes And Measures: Number and type of failures involving use of transmission-based precautions.

Results: In total, 325 room observations were conducted at 2 sites. At site 1, a total of 280 observations were completed (196 in medical/surgical units, 64 in intensive care units, and 20 in emergency departments). At site 2, there were 45 observations (36 in medical/surgical units and 9 in the intensive care unit). Of the total observations, 259 (79.7%) occurred outside and 66 (20.3%) inside the room. Two hundred eighty-three failures were observed, including 102 violations (deviations from safe operating practices or procedures), 144 process or procedural mistakes (failures of intention), and 37 slips (failures of execution). Violations involved entering rooms without some or all recommended PPE. Mistakes were frequently observed during PPE removal and encounters with challenging logistical situations, such as badge-enforced computer logins. Slips included touching one's face or clean areas with contaminated gloves or gowns. Each of these active failures has a substantial likelihood of resulting in self-contamination. The circumstances surrounding failures in precaution practices, however, varied not only across but within the different failure types.

Conclusions And Relevance: Active failures in PPE use and transmission-based precautions, potentially leading to self-contamination, were commonly observed. The factors that contributed to these failures varied widely, suggesting the need for a range of strategies to reduce potential transmission risk during routine hospital care.
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http://dx.doi.org/10.1001/jamainternmed.2018.1898DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6583062PMC
August 2018

Transmission of Clostridium difficile from asymptomatically colonized or infected long-term care facility residents.

Infect Control Hosp Epidemiol 2018 08 31;39(8):909-916. Epub 2018 May 31.

6Edward Hines,Jr Veterans Affairs Hospital,Hines,Illinois.

Objective: To test the hypothesis that long-term care facility (LTCF) residents with Clostridium difficile infection (CDI) or asymptomatic carriage of toxigenic strains are an important source of transmission in the LTCF and in the hospital during acute-care admissions.

Design: A 6-month cohort study with identification of transmission events was conducted based on tracking of patient movement combined with restriction endonuclease analysis (REA) and whole-genome sequencing (WGS).

Setting: Veterans Affairs hospital and affiliated LTCF.ParticipantsThe study included 29 LTCF residents identified as asymptomatic carriers of toxigenic C. difficile based on every other week perirectal screening and 37 healthcare facility-associated CDI cases (ie, diagnosis >3 days after admission or within 4 weeks of discharge to the community), including 26 hospital-associated and 11 LTCF-associated cases.

Results: Of the 37 CDI cases, 7 (18·9%) were linked to LTCF residents with LTCF-associated CDI or asymptomatic carriage, including 3 of 26 hospital-associated CDI cases (11·5%) and 4 of 11 LTCF-associated cases (36·4%). Of the 7 transmissions linked to LTCF residents, 5 (71·4%) were linked to asymptomatic carriers versus 2 (28·6%) to CDI cases, and all involved transmission of epidemic BI/NAP1/027 strains. No incident hospital-associated CDI cases were linked to other hospital-associated CDI cases.

Conclusions: Our findings suggest that LTCF residents with asymptomatic carriage of C. difficile or CDI contribute to transmission both in the LTCF and in the affiliated hospital during acute-care admissions. Greater emphasis on infection control measures and antimicrobial stewardship in LTCFs is needed, and these efforts should focus on LTCF residents during hospital admissions.
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http://dx.doi.org/10.1017/ice.2018.106DOI Listing
August 2018

The Drivers of Acute and Long-term Care Clostridium difficile Infection Rates: A Retrospective Multilevel Cohort Study of 251 Facilities.

Clin Infect Dis 2017 10;65(8):1282-1288

Salt Lake Veterans Affairs Medical Center, Salt Lake City, UT.

Background: Drivers of differences in Clostridium difficile incidence across acute and long-term care facilities are poorly understood. We sought to obtain a comprehensive picture of C. difficile incidence and risk factors in acute and long-term care.

Methods: We conducted a case-cohort study of persons spending at least 3 days in one of 131 acute care or 120 long-term care facilities managed by the United States Veterans Health Administration between 2006 and 2012. Patient (n = 8) and facility factors (n = 5) were included in analyses. The outcome was the incidence of facility-onset laboratory-identified C. difficile infection (CDI), defined as a person with a positive C. difficile test without a positive test in the prior 8 weeks.

Results: CDI incidence in acute care was 5 times that observed in long-term care (median, 15.6 vs 3.2 per 10000 person-days). History of antibiotic use was greater in acute care compared to long-term care (median, 739 vs 513 per 1000 person-days) and explained 72% of the variation in C. difficile rates. Importation of C. difficile cases (acute care: patients with recent long-term care attributable infection; long-term care: residents with recent acute care attributable infection) was 3 times higher in long-term care as compared to acute care (median, 52.3 vs 16.2 per 10000 person-days).

Conclusions: Facility-level antibiotic use was the main factor driving differences in CDI incidence between acute and long-term care. Importation of acute care C. difficile cases was a greater concern for long-term care as compared to importation of long-term care cases for acute care.
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http://dx.doi.org/10.1093/cid/cix532DOI Listing
October 2017

Feasibility of Population Health Analytics and Data Visualization for Decision Support in the Infectious Diseases Domain: A pilot study.

Appl Clin Inform 2016 29;7(2):604-23. Epub 2016 Jun 29.

Department of Biomedical Informatics, University of Utah, 421 Wakara Way, Salt Lake City, UT 84108, USA; IDEAS Center for Innovation, VA Salt Lake City Health System, 500 Foothill Drive, Salt Lake City, UT 84108, USA.

Objective: Big data or population-based information has the potential to reduce uncertainty in medicine by informing clinicians about individual patient care. The objectives of this study were: 1) to explore the feasibility of extracting and displaying population-based information from an actual clinical population's database records, 2) to explore specific design features for improving population display, 3) to explore perceptions of population information displays, and 4) to explore the impact of population information display on cognitive outcomes.

Methods: We used the Veteran's Affairs (VA) database to identify similar complex patients based on a similar complex patient case. Study outcomes measures were 1) preferences for population information display 2) time looking at the population display, 3) time to read the chart, and 4) appropriateness of plans with pre- and post-presentation of population data. Finally, we redesigned the population information display based on our findings from this study.

Results: The qualitative data analysis for preferences of population information display resulted in four themes: 1) trusting the big/population data can be an issue, 2) embedded analytics is necessary to explore patient similarities, 3) need for tools to control the view (overview, zoom and filter), and 4) different presentations of the population display can be beneficial to improve the display. We found that appropriateness of plans was at 60% for both groups (t9=-1.9; p=0.08), and overall time looking at the population information display was 2.3 minutes versus 3.6 minutes with experts processing information faster than non-experts (t8= -2.3, p=0.04).

Conclusion: A population database has great potential for reducing complexity and uncertainty in medicine to improve clinical care. The preferences identified for the population information display will guide future health information technology system designers for better and more intuitive display.
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http://dx.doi.org/10.4338/ACI-2015-12-RA-0182DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4941864PMC
November 2017

Supporting novice clinicians cognitive strategies: System design perspective.

IEEE EMBS Int Conf Biomed Health Inform 2016 Feb;2016:509-512

University of Utah, Salt Lake City, UT. USA.

Infections occur among all clinical domains. The changing nature of microbes, viruses and infections poses a great threat to the overall well-being in medicine. Clinicians in the infectious disease (ID) domain deal with diagnostic as well as treatment uncertainty in their everyday practice. Our current health information technology (HIT) systems do not consider the level of clinician expertise into the system design process. Thus, information is presented to both novice and expert ID clinicians in identical ways. The purpose of this study was to identify the cognitive strategies novice ID clinicians use in managing complex cases to make better recommendations for system design. In the process, we interviewed 14 ID experts and asked them to give us a detailed description of how novice clinicians would have dealt with complex cases. From the interview transcripts, we identified four major themes that expert clinicians suggested about novices' cognitive strategies including: A) dealing with uncertainty, B) lack of higher macrocognition, C) oversimplification of problems through heuristics and D) dealing with peer pressure. Current and future innovative decision support tools embedded in the electronic health record that can match these cognitive strategies may hold the key to cognitively supporting novice clinicians. The results of this study may open up avenues for future research and suggest design directions for better healthcare systems.
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http://dx.doi.org/10.1109/BHI.2016.7455946DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4888895PMC
February 2016

Human Rabies - Wyoming and Utah, 2015.

MMWR Morb Mortal Wkly Rep 2016 Jun 3;65(21):529-33. Epub 2016 Jun 3.

In September 2015, a Wyoming woman was admitted to a local hospital with a 5-day history of progressive weakness, ataxia, dysarthria, and dysphagia. Because of respiratory failure, she was transferred to a referral hospital in Utah, where she developed progressive encephalitis. On day 8 of hospitalization, the patient's family told clinicians they recalled that, 1 month before admission, the woman had found a bat on her neck upon waking, but had not sought medical care. The patient's husband subsequently had contacted county invasive species authorities about the incident, but he was not advised to seek health care for evaluation of his wife's risk for rabies. On October 2, CDC confirmed the patient was infected with a rabies virus variant that was enzootic to the silver-haired bat (Lasionycteris noctivagans). The patient died on October 3. Public understanding of rabies risk from bat contact needs to be improved; cooperation among public health and other agencies can aid in referring persons with possible bat exposure for assessment of rabies risk.
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http://dx.doi.org/10.15585/mmwr.mm6521a1DOI Listing
June 2016

Importation, Antibiotics, and Clostridium difficile Infection in Veteran Long-Term Care: A Multilevel Case-Control Study.

Ann Intern Med 2016 06 19;164(12):787-94. Epub 2016 Apr 19.

Background: Although clinical factors affecting a person's susceptibility to Clostridium difficile infection are well-understood, little is known about what drives differences in incidence across long-term care settings.

Objective: To obtain a comprehensive picture of individual and regional factors that affect C difficile incidence.

Design: Multilevel longitudinal nested case-control study.

Setting: Veterans Health Administration health care regions, from 2006 through 2012.

Participants: Long-term care residents.

Measurements: Individual-level risk factors included age, number of comorbid conditions, and antibiotic exposure. Regional risk factors included importation of cases of acute care C difficile infection per 10 000 resident-days and antibiotic use per 1000 resident-days. The outcome was defined as a positive result on a long-term care C difficile test without a positive result in the prior 8 weeks.

Results: 6012 cases (incidence, 3.7 cases per 10 000 resident-days) were identified in 86 regions. Long-term care C difficile incidence (minimum, 0.6 case per 10 000 resident-days; maximum, 31.0 cases per 10 000 resident-days), antibiotic use (minimum, 61.0 days with therapy per 1000 resident-days; maximum, 370.2 days with therapy per 1000 resident-days), and importation (minimum, 2.9 cases per 10 000 resident-days; maximum, 341.3 cases per 10 000 resident-days) varied substantially across regions. Together, antibiotic use and importation accounted for 75% of the regional variation in C difficile incidence (R2 = 0.75). Multilevel analyses showed that regional factors affected risk together with individual-level exposures (relative risk of regional antibiotic use, 1.36 per doubling [95% CI, 1.15 to 1.60]; relative risk of importation, 1.23 per doubling [CI, 1.14 to 1.33]).

Limitations: Case identification was based on laboratory criteria. Admission of residents with recent C difficile infection from non-Veterans Health Administration acute care sources was not considered.

Conclusion: Only 25% of the variation in regional C difficile incidence in long-term care remained unexplained after importation from acute care facilities and antibiotic use were accounted for, which suggests that improved infection control and antimicrobial stewardship may help reduce the incidence of C difficile in long-term care settings.

Primary Funding Source: U.S. Department of Veterans Affairs and Centers for Disease Control and Prevention.
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http://dx.doi.org/10.7326/M15-1754DOI Listing
June 2016

Healthcare personnel attire in non-operating-room settings.

Infect Control Hosp Epidemiol 2014 Feb;35(2):107-21

Virginia Commonwealth University, Richmond, Virginia.

Healthcare personnel (HCP) attire is an aspect of the medical profession steeped in culture and tradition. The role of attire in cross-transmission remains poorly established, and until more definitive information exists priority should be placed on evidence-based measures to prevent healthcare-associated infections (HAIs). This article aims to provide general guidance to the medical community regarding HCP attire outside the operating room. In addition to the initial guidance statement, the article has 3 major components: (1) a review and interpretation of the medical literature regarding (a) perceptions of HCP attire (from both HCP and patients) and (b) evidence for contamination of attire and its potential contribution to cross-transmission; (2) a review of hospital policies related to HCP attire, as submitted by members of the Society for Healthcare Epidemiology of America (SHEA) Guidelines Committee; and (3) a survey of SHEA and SHEA Research Network members that assessed both institutional HCP attire policies and perceptions of HCP attire in the cross-transmission of pathogens. Recommendations for HCP attire should attempt to balance professional appearance, comfort, and practicality with the potential role of apparel in the cross-transmission of pathogens. Although the optimal choice of HCP attire for inpatient care remains undefined, we provide recommendations on the use of white coats, neckties, footwear, the bare-below-the-elbows strategy, and laundering. Institutions considering these optional measures should introduce them with a well-organized communication and education effort directed at both HCP and patients. Appropriately designed studies are needed to better define the relationship between HCP attire and HAIs.
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http://dx.doi.org/10.1086/675066DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4820072PMC
February 2014

Utility of a commercial PCR assay and a clinical prediction rule for detection of toxigenic Clostridium difficile in asymptomatic carriers.

J Clin Microbiol 2014 Jan 23;52(1):315-8. Epub 2013 Oct 23.

Geriatric Research, Education, and Clinical Center, Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA.

A commercial PCR assay of perirectal swab specimens detected 17 (68%) of 25 asymptomatic carriers of toxigenic Clostridium difficile, including 93% with skin and/or environmental contamination. A clinical prediction rule, followed by PCR screening, could be used to identify carriers at high risk of C. difficile shedding.
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http://dx.doi.org/10.1128/JCM.01852-13DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3911416PMC
January 2014

Description of outbreaks of health-care-associated infections related to compounding pharmacies, 2000-12.

Am J Health Syst Pharm 2013 Aug;70(15):1301-12

Department of Biomedical Informatics, University of Utah, Salt Lake City, UT 84112, USA.

Purpose: Outbreaks of health-care-associated infections related to compounding pharmacies from 2000 through 2012 are described.

Methods: PubMed and the websites for the Centers for Disease Control and Prevention and the Food and Drug Administration were searched to identify infectious outbreaks associated with compounding pharmacies outside the hospital setting between January 2000 and November 2012.

Results: Between January 2000 and before the 2012 fungal meningitis outbreak, 11 outbreaks were identified, involving 207 infected patients and 17 deaths after exposure to contaminated compounded drugs. The 2012 meningitis outbreak had a similar mortality rate but increased these totals almost fivefold. Half of the outbreaks involved patients in more than one state. Three outbreaks involved ophthalmic drugs. The remaining outbreaks involved corticosteroids, heparin flush solutions, cardioplegia solution, i.v. magnesium sulfate, total parenteral nutrition, and fentanyl. The outbreaks were caused by pathogens commonly associated with health-care-associated infections, common skin commensals, and organisms that rarely cause infection. Morbidity was substantial, including vision loss. Half the outbreaks resulted in recall of all sterile drugs from the pharmacy due to systemic problems with sterile procedures.

Conclusion: Before the nationwide 2012 fungal meningitis outbreak, drugs produced by compounding pharmacies were associated with 11 other smaller, but equally serious, outbreaks that occurred sporadically over the past 12 years. Lapses in sterile compounding procedures led to contamination of compounded drugs, exposure to patients, and a threat to public health in these outbreaks. Recognition and subsequent public health investigation were usually triggered by the occurrence of illness among multiple patients in a single health care setting.
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http://dx.doi.org/10.2146/ajhp130049DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3886339PMC
August 2013

Evaluation of 2009 pandemic influenza A (H1N1) exposures and illness among physicians in training.

Am J Infect Control 2012 Sep 22;40(7):617-21. Epub 2012 May 22.

Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, Cincinnati, OH 45226, USA.

Background: A cluster of influenza-like illness (ILI) among physicians in training during the 2009 influenza A (H1N1) pandemic (pH1N1) led to a health hazard evaluation.

Methods: We conducted a cross-sectional study to examine exposures, infection control practices, ILI prevalence, and transmission among physicians in training at 4 affiliated hospitals during the pandemic. We administered an electronic survey and met with physicians in training and hospital personnel.

Results: Of the 88 responding physicians, 85% reported exposure to pH1N1. Exposures occurred at work from patients or coworkers and outside of work from coworkers, household members, or the community. Thirteen cases of ILI were reported in May-June 2009; 10 respondents reported working while ill (duration, 1-4 days). Between 13% and 88% of respondents knew which personal protective equipment (PPE) was recommended when caring for influenza patients at the 4 hospitals. The most common reasons for not using PPE were not knowing that a patient had pH1N1 or ILI and not having PPE readily available.

Conclusions: Physicians in training have gaps in their knowledge of and adherence to recommended PPE and compliance with work restrictions. Our findings underscore the importance of installing isolation precaution signage, making PPE readily available near patients with influenza, and facilitating work restrictions for ill health care personnel.
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http://dx.doi.org/10.1016/j.ajic.2012.01.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4555992PMC
September 2012

Agreement in classifying bloodstream infections among multiple reviewers conducting surveillance.

Clin Infect Dis 2012 Aug 26;55(3):364-70. Epub 2012 Apr 26.

University of Utah School of Medicine, Salt Lake City, USA.

Background: Mandatory reporting of healthcare-associated infections (HAIs) is increasing. Evidence for agreement among different reviewers applying HAI surveillance criteria is limited. We aim to characterize agreement among infection preventionists (IPs) conducting surveillance for central line-associated bloodstream infection (CLABSI) with each other and as compared with simplified laboratory-based definitions.

Methods: Abstracted electronic health records were assembled from inpatients with positive blood cultures at a tertiary-care Veterans Affairs (VA) hospital over a 5-year period. Identical patient records were made available to VA IPs from different facilities to report on CLABSI using their usual surveillance methods. Positive blood cultures were also evaluated using laboratory-based definitions. Standard indices of interrater agreement, expressed as a κ statistic, were computed between IPs, and between IPs and simplified laboratory-based methods.

Results: Overall, 114 patient records were reviewed by 18 IPs, the majority of whom specified they followed National Healthcare Safety Network criteria. The overall agreement among IPs by κ statistic was 0.42 (standard error [SE], 0.06). IPs had better agreement with a simple laboratory-based definition with an average κ of 0.55 (SE, 0.05). The proportion of patient records that 18 IPs reported with CLABSI ranged from 14% to 39% (overall mean, 28% with a coefficient of variation of 25%). When simple laboratory-based methods were applied to different sets of patient records, classification was more consistent with CLABSI assigned in a proportion ranging from 36% to 42% (overall mean, 39%).

Conclusions: Reliability of IP-conducted surveillance to identify HAI may not be ideal for public reporting goals of interhospital comparisons.
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http://dx.doi.org/10.1093/cid/cis410DOI Listing
August 2012

A multicenter study of Clostridium difficile infection-related colectomy, 2000-2006.

Infect Control Hosp Epidemiol 2012 May 20;33(5):470-6. Epub 2012 Mar 20.

Washington University School of Medicine, St. Louis, Missouri, USA.

Objective: To assess Clostridium difficile infection (CDI)-related colectomy rates by CDI surveillance definitions and over time at multiple healthcare facilities.

Setting: Five university-affiliated acute care hospitals in the United States.

Design And Methods: Cases of CDI and patients who underwent colectomy from July 2000 through June 2006 were identified from 5 US tertiary care centers. Monthly CDI-related colectomy rates were calculated as the number of CDI-related colectomies per 1,000 CDI cases, and cases were categorized according to recommended surveillance definitions. Logistic regression was performed to evaluate risk factors for CDI-related colectomy.

Results: In total, 8,569 cases of CDI were identified, and 75 patients underwent CDI-related colectomy. The overall colectomy rate was 8.7 per 1,000 CDI cases. The CDI-related colectomy rate ranged from 0 to 23 per 1,000 CDI episodes across hospitals. The colectomy rate for healthcare-facility-onset CDI was 4.3 per 1,000 CDI cases, and that for community-onset CDI was 16.5 per 1,000 CDI cases (P < .05). There were significantly more CDI-related colectomies at hospitals B and C (P < .05).

Conclusions: The overall CDI-related colectomy rate was low, and there was no significant change in the CDI-related colectomy rate over time. Onset of disease outside the study hospital was an independent risk factor for colectomy.
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http://dx.doi.org/10.1086/665318DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3657463PMC
May 2012
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