IDWeek: Should you wash your hands after tying your shoes?

In these highlights from our coverage of IDWeek 2021, held virtually, we present the latest findings about the effects of the COVID-19 pandemic on antibiotic stewardship and hand hygiene, including whether we should be washing our hands after tying our shoes.

After an initial spike in antibiotic prescribing at Veterans Affairs’ medical centers during the COVID-19 pandemic, antibiotic use returned to prepandemic levels, according to a study’s lead researcher, Matt Goetz, MD, the chief of infectious diseases at the VA Greater Los Angeles Healthcare System (poster 170). “In our previously published work, we demonstrated that antibiotic use in the VA increased by 11% in the first five months of 2020, largely reversing declines in VA antimicrobial utilization that had occurred since 2015,” Dr. Goetz said. “We wanted to see whether these changes persisted throughout the COVID-19 pandemic.”

ALBUTEIN® 25% (albumin [human] U.S.P.) is indicated for: hypovolemia, cardiopulmonary bypass procedures, acute nephrosis, hypoalbuminemia, ovarian hyperstimulation syndrome, neonatal hyperbilirubinemia, adult respiratory distress syndrome (ARDS), and prevention of central volume depletion after paracentesis due to cirrhotic ascites. ALBUTEIN® 5% (albumin [human] U.S.P.) is indicated for: hypovolemia, cardiopulmonary bypass procedures, hypoalbuminemia, and plasma exchange. ALBUTEIN 5% and 25% are contraindicated in patients with a history of hypersensitivity to albumin preparations or to any of the excipients, and in patients with severe anemia or cardiac failure with normal or increased intravascular volume. Allergic or anaphylactic reactions require immediate discontinuation of the infusion and implementation of appropriate medical treatment.

Hypervolemia may occur if the dosage and rate of infusion are not adjusted to the patient’s volume status. At the first clinical signs of fluid overload, the infusion must be slowed or stopped immediately. Use albumin with caution in conditions where hypervolemia and its consequences or hemodilution could represent a special risk to the patient. The colloid-osmotic effect of human albumin 25% is approximately five times that of blood plasma. Therefore, when concentrated albumin is administered, care must be taken to assure adequate hydration of the patient. Patients should be monitored carefully to guard against circulatory overload and hyperhydration. Patients with marked dehydration require administration of additional fluids.

Concentrated (20% - 25%) human albumin solutions are relatively low in electrolytes compared to 4% - 5% human albumin solutions. Regularly monitor the electrolyte status of the patient and take appropriate steps to restore or maintain the electrolyte balance when albumin is administered. Regular monitoring of coagulation and hematology parameters is necessary if comparatively large volumes are to be replaced. Care must be taken to ensure adequate substitution of other blood constituents (coagulation factors, electrolytes, platelets and erythrocytes). Regularly monitor hemodynamic parameters during administration of ALBUTEIN® 5% and 25% (albumin [human] U.S.P.). ALBUTEIN 5% and 25% must not be diluted with sterile water for injection as this may cause hemolysis in recipients. Albumin is a derivative of human blood. Based on effective donor screening and product manufacturing processes, it carries an extremely remote risk for transmission of viral diseases. A theoretical risk for transmission of Creutzfeldt-Jakob disease (CJD) is also considered extremely remote. No cases of transmission of viral diseases or CJD have ever been identified for ALBUTEIN 5% or 25%.

The most serious adverse reactions with use of albumin are anaphylactic shock, heart failure and pulmonary edema. The most common adverse reactions are anaphylactoid type reactions. Adverse reactions to ALBUTEIN normally resolve when the infusion rate is slowed or the infusion is stopped. In case of severe reactions, the infusion should be stopped and appropriate treatment initiated.

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Dr. Goetz and his team analyzed data on antimicrobial use in acute inpatient care units at 108 level 1 VA facilities and two other VA facilities between January 2020 and February 2021. They included COVID-19 and non–COVID-19 patients. A level 1 unit cares for the most complex, high-risk patients.

Monthly total acute care antibiotic use increased from a low of 533 days of treatment per 1,000 patient care days in January 2020, to 583 days of treatment per 1,000 days of care in April 2020. After that initial rise, antibiotic use declined to 495 days of treatment per 1,000 days of care in September 2020, and remained at prepandemic levels subsequently, with fewer than 500 days of treatment per 1,000 days of care in February 2021.

“This decrease [occurred] despite rises in COVID-19 care, which accounted for 24% of all patient care in January 2021,” Dr. Goetz noted.

When the investigators analyzed antibiotic use patterns according to COVID-19 and non–COVID-19 patients, they found antibiotic use decreased from a high of 550 days of treatment per 1,000 days of care during the early phase of the pandemic for non–COVID-19 patients to 509 days of treatment per 1,000 days of care between November 2020 and February 2021 for this group. Similarly, antibiotic use among COVID-19 patients dropped from a peak of 590 days of treatment per 1,000 days of care in the early phase of the pandemic to 528 days of treatment per 1,000 days of care between November 2020 and February 2021.

“These data support the continued effectiveness of antimicrobial stewardship programs in the VA,” Dr. Goetz concluded.

The COVID-19 pandemic increased attention to hand hygiene, but did it really have a lasting effect? Not likely, according to a behavior study (poster 422).

“Hand hygiene is an important infection prevention and control practice to limit the transmission of infection, including COVID-19, in a health care setting,” said Victoria Williams, MPH, an infection prevention and control epidemiologist at Sunnybrook Health Sciences Centre, in Toronto.

To evaluate long-term hand hygiene performance through subsequent waves of the pandemic, Ms. Williams and her colleagues studied the practice at 56 inpatient, acute care units located in six university and seven community acute care hospitals in Ontario.

An electronic monitoring system tracked the use of alcohol hand rub and soap sink dispensers located in and outside of patient rooms. Data were collected from Nov. 1, 2019, through May 31, 2021, and divided into a prepandemic baseline period and three subsequent COVID-19 waves: 1. wave 1 (March 1 through June 30, 2020); 2. wave 2 (Oct. 1, 2020, through Feb. 28, 2021); and 3. wave 3 (March 1 through May 31, 2021).

During the baseline period of Nov. 1 through Dec. 20, 2020, median adherence to hand hygiene was 43% and peak adherence reached 49%.

Hand hygiene performance rose before the arrival of the first COVID-19 wave in Ontario, likely as news began to spread about the pandemic. During wave 1, adherence increased sharply, reaching a median of 64% and peak of 79%.

However, the improvement was not sustained. Hand hygiene adherence returned to baseline following wave 1

ALBUTEIN 5% is an albumin solution indicated for: • Hypovolemia. • Cardiopulmonary bypass procedures. • Hypoalbuminemia. • Plasma exchange.

Dosage and infusion rate should be adjusted to the patient’s individual requirements.

Hypovolemia

Cardiopulmonary bypass procedures Adults: Initial dose of 20 g (including renal dialysis). For acute liver failure: initial dose of 12 to 25 g.

Adults: Initial dose of 25 g.

Hypoalbuminemia

Adults: 50 to 75 g For pre- and post-operative hypoproteinemia: 50 to 75 g. For burn therapy after the first 24 h: initial dose of 25 g and dose adjustment to maintain plasma protein concentration of 2.5 g per 100 mL. Third space protein loss due to infection: initial dose of 50 to 100 g. Plasma exchange The dose required depends on the volume of plasma removed during the procedure. Do not dilute with sterile water for injection as this may cause hemolysis in recipients.

ALBUTEIN 5% is a solution containing 50 g per L of total protein of which at least 95% is human albumin.

• Hypersensitivity to albumin preparations or to any of the excipients. • Severe anemia or cardiac failure with normal or increased intravascular volume.

• Suspicion of allergic or anaphylactic reactions requires immediate discontinuation of the injection and implementation of appropriate medical treatment. • Hypervolemia may occur if the dosage and rate of infusion are not adjusted to the patient’s volume status. Use with caution in conditions where hypervolemia and its consequences or hemodilution could represent a special risk to the patient. • Monitor electrolytes, coagulation and hematology parameters, and hemodynamic status when albumin is given. • Do not dilute with sterile water for injection. • This product is made from human plasma and may contain infectious agents, e.g., viruses and, theoretically, the Creutzfeldt-Jakob disease agent.

The most common adverse reactions are anaphylactoid type reactions.

• Pregnancy: No human or animal data. Use only if clearly needed.

Manufactured by:

5555 Valley Boulevard Los Angeles, CA 90032, U.S.A. U.S. License No. 1694 3061038

ALBUTEIN 25% is an albumin solution indicated for: • Hypovolemia. • Cardiopulmonary bypass procedures. • Acute nephrosis. • Hypoalbuminemia. • Ovarian hyperstimulation syndrome. • Neonatal hyperbilirubinemia. • Adult respiratory distress syndrome (ARDS). • Prevention of central volume depletion after paracentesis due to cirrhotic ascites.

Dosage and infusion rate should be adjusted to the patient’s individual requirements.

Hypovolemia

Cardiopulmonary bypass procedures Adults: Initial dose of 25 g (including renal dialysis). For acute liver failure: initial dose of 12 to 25 g.

Adults: Initial dose of 25 g.

Acute nephrosis Adults: 25 g together with diuretic once a day for 7 - 10 days. Adults: 50 to 75 g For pre- and post-operative hypoproteinemia: 50 to 75 g. For burn therapy after the first 24 h: initial dose of 25 g and dose adjustment to maintain plasma protein concentration of 2.5 g per 100 mL. Third space protein loss due to infection: initial dose of 50 to 100 g. Adults: 50 g to 100 g over 4 hours and repeated at 4-12 hour intervals as necessary.

Neonatal hyperbilirubinemia 1 g per kilogram body weight prior to or during exchange transfusion.

Adult respiratory distress syndrome (ARDS) Adults: 25 g over 30 minutes and repeated at 8 hours for 3 days, if necessary.

Prevention of central volume depletion after paracentesis due to cirrhotic ascites Adults: 8 g for every 1000 mL of ascitic fluid removed. Do not dilute with sterile water for injection as this may cause hemolysis in recipients.

ALBUTEIN 25% is a solution containing 250 g per L of total protein of which at least 95% is human albumin.

• Hypersensitivity to albumin preparations or to any of the excipients. • Severe anemia or cardiac failure with normal or increased intravascular volume.

• Suspicion of allergic or anaphylactic reactions requires immediate discontinuation of the injection and implementation of appropriate medical treatment. • Hypervolemia may occur if the dosage and rate of infusion are not adjusted to the patient’s volume status. Use with caution in conditions where hypervolemia and its consequences or hemodilution could represent a special risk to the patient. • When concentrated albumin is administered, care must be taken to assure adequate hydration of the patient. • Monitor electrolytes, coagulation and hematology parameters, and hemodynamic status when albumin is administered. • Do not dilute with sterile water for injection. • This product is made from human plasma and may contain infectious agents, e.g., viruses and, theoretically, the Creutzfeldt-Jakob disease agent.

The most common adverse reactions are anaphylactoid type reactions.

• Pregnancy: No human or animal data. Use only if clearly needed.

of the pandemic, and did not measurably increase over the course of wave 2 (median, 49%; peak, 53%) or wave 3 (median, 47%; peak, 52%).

“The increase in hand hygiene adherence seen during wave 1 of the COVID-19 pandemic indicates high levels of adherence are possible in response to events,” Ms. Williams said. “But quality improvement initiatives are required to sustain the change in practice.

“In this specific instance,” Ms. Williams continued, “the improvement was likely associated with fear and desire for self-preservation in the context of a novel pathogen. Once the perceived risk of COVID-19 had decreased, hand hygiene decreased as well, despite subsequent community waves of infection.”

Strongly consider washing your hands the next time you tie your shoelaces. According to an international study of nearly 12,000 environmental isolates, up to 45% of samples from shoe soles contain Clostridioides difficile spores. The pathogen also was found on surfaces and floors in houses, parks and public buildings (oral abstract 18).

Considering that one-third of C. difficile infections (CDIs) originate in the community, researchers are urging at-risk individuals to implement measures to minimize exposure to the pathogen.

“[I would advise] patients at high risk of [CDI] to clean their house with a sporicidal and, if you’re going out into the community, for the first month after hospitalization, wear a mask,” said senior investigator Kevin Garey, PharmD, a professor of pharmacy practice and the chair of the Department of Pharmacy Practice and Translational Research at the University of Houston College of Pharmacy. Lead researcher Jinhee Jo, PharmD, a postdoctoral infectious disease fellow in Dr. Garey’s laboratory, and her colleagues collected 11,986 environmental samples in the United States and nine other countries in Europe, Asia, and Central and South America between 2014 and 2017. The samples came from outdoor environments, private residences, shoe soles, public buildings and acute care settings. Positive samples underwent confirmatory polymerase chain reaction (PCR) testing for toxin genes and fluorescent PCR ribotyping.

According to Dr. Jo, 27% of the samples tested positive for toxigenic C. difficile, with similar rates in the United States and other countries. Samples from shoe soles had the highest positivity rate, at 45%, and the ribotypes

were similar for shoe soles and surrounding environmental samples. Other non–health care locations with high positivity rates were private residences (26.2%), outdoor environments (24.1%) and public buildings (17.2%). A subanalysis of samples from Texas showed that 24% of isolates from health care facilities included C. difficile spores. Dr. Jo noted that it is possible shoe soles could serve as a vector for C. difficile transmission—and possibly other pathogens that cause what usually bui u ldings are considered health care–associated infections—but more studies are needt ed to confirm that suspicion. f- In the interim, she said community DIs) infection control measures may help om- reduce transmission. Interventions s might include disinfecting floors in dividuals to public buildings and other areas with high foot traffic, such as universities and grocery stores, she said. Dr. Garey added that although there is no evidence that removing shoes indoors reduces the likelihood of CDI, it makes intuitive sense to do so as a way of reducing risk for C. difficile transmission.

c a A 201 outdo re r sid build

—David Wild and Ethan Covey

Robert Adamson, PharmD, Livingston, NJ James A. Jorgenson, MS, RPh, St. Paul, MN Indu Lew, PharmD, Livingston, NJ

Meghan D. Swarthout, PharmD, MBA, BCPS, Sallston, MD

Julie A. Golembiewski, PharmD, Chicago, IL David S. Craig, PharmD, BCPS, Tampa, FL Robert L. Barkin, MBA, PharmD, Chicago, IL

C. Michael White, PharmD, Storrs, CT

Lawrence Cohen, PharmD, FASHP, FCCP, Fort Worth, TX

Cathy Rosenbaum, PharmD, Cincinnati, OH

Judi Jacobi, PharmD, FCCM, Indianapolis, IN

Steven J. Martin, PharmD, BCPS, FCCM, Toledo, OH David P. Nicolau, PharmD, Hartford, CT Jason Pogue, PharmD, Detroit, MI

ErnestR. Anderson Jr., MS, RPh, Boston, MA Elaine Strauss, PharmD, MS, Atlanta, GA

Jeffrey Norenberg, PharmD, Albuquerque, NM

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