COVID-19 symptoms predictive of healthcare workers' SARS-CoV-2 PCR results

Background Coronavirus 2019 disease (COVID-19) is caused by the virus SARS-CoV-2, transmissible both person-to-person and from contaminated surfaces. Early COVID-19 detection among healthcare workers (HCWs) is crucial for protecting patients and the healthcare workforce. Because of limited testing capacity, symptom-based screening may prioritize testing and increase diagnostic accuracy. Methods and findings We performed a retrospective study of HCWs undergoing both COVID-19 telephonic symptom screening and nasopharyngeal SARS-CoV-2 assays during the period, March 9.April 15, 2020. HCWs with negative assays but progressive symptoms were re-tested for SARSCoV- 2. Among 592 HCWs tested, 83 (14%) had an initial positive SARS-CoV-2 assay. Fiftynine of 61 HCWs (97%) who were asymptomatic or reported only sore throat/nasal congestion had negative SARS-CoV-2 assays (P = 0.006). HCWs reporting three or more symptoms had an increased multivariate-adjusted odds of having positive assays, 1.95 (95% CI: 1.10.3.64), which increased to 2.61 (95% CI: 1.50.4.45) for six or more symptoms. The multivariate-adjusted odds of a positive assay were also increased for HCWs reporting fever and a measured temperature . 37.5°C (3.49 (95% CI: 1.95.6.21)), and those with myalgias (1.83 (95% CI: 1.04.3.23)). Anosmia/ageusia (i.e. loss of smell/loss of taste) was reported less frequently (16%) than other symptoms by HCWs with positive assays, but was associated with more than a seven-fold multivariate-adjusted odds of a positive test: OR = 7.21 (95% CI: 2.95.17.67). Of 509 HCWs with initial negative SARS-CoV-2 assays, nine had symptom progression and positive re-tests, yielding an estimated negative predictive value of 98.2% (95% CI: 96.8-99.0%) for the exclusion of clinically relevant COVID-19. Conclusions Symptom and temperature reports are useful screening tools for predicting SARS-CoV-2 assay results in HCWs. Anosmia/ageusia, fever, and myalgia were the strongest independent predictors of positive assays. The absence of symptoms or symptoms limited to nasal congestion/sore throat were associated with negative assays

A Successful Strategy to Reduce Hospital-Onset Clostridium difficile

Abstract Background: Our goal was to reduce the rate of hospital-onset (HO) C. difficile (CD) by prompt testing in patients with diarrhea on hospital day (HD) 1–3 using a nurse-driven testing protocol (NTP) with PCR and improve identification of disease after HD 3 using a combined toxin/antigen assay (TAA). Methods: An automated best practice advisory/NTP was developed in Epic, triggered by documentation of diarrhea during HD 1–3, to facilitate prompt stool collection, testing and initiation of contact precautions. Education was provided. The NTP was fully implemented at 2 community-teaching hospitals mid-February 2016. The TAA was adopted 7/27/16 for testing after HD 3. Results: In 2016, the standardized infection ratio (SIR) at Cambridge and Everett was 0.43 (P = 0.009) and 0.5 (P = 0.017), respectively, reflecting a 48–61% decrease from 2015. There was a 14–28% improvement in identifying cases as community-onset. The TAA led to a further decline in HO-CD by 10–61%. Refer to the graph for quarterly SIRs before and after implementation. Despite a 26% increase in testing volume, costs are less with the current strategy. Conclusion: Prompt identification of CD improves care and prevents inflation of HO-CD. This strategy has enhanced our efforts to reduce our SIR (observed/expected cases) and resulted in a substantial incentive payment for CHA. Disclosures All authors: No reported disclosures

A pilot study of antibiotic cycling in the community hospital setting

OBJECTIVE: To assess the feasibility of a quarterly antibiotic cycling program at two community hospitals and to evaluate its safety and impact on antibiotic use, expenditures, and resistance. DESIGN: Nonrandomized, longitudinal cohort study. SETTING: Two community hospitals, one teaching and one non-teaching. PATIENTS: Adult medical and surgical inpatients requiring empiric antibiotic therapy. INTERVENTION: We developed and implemented a treatment protocol for the empiric therapy of common infections. Between July 2000 and June 2002, antibiotics were cycled quarterly; quinolones, beta-lactam-inhibitor combinations, and cephalosporins were used. Protocol adherence, adverse drug events, nosocomial infections, antibiotic use and expenditures, resistance among clinical isolates, and length of stay were assessed during eight quarters. RESULTS: Physicians adhered to the protocol for more than 96% of 2,494 eligible patients. No increases in nosocomial infections or adverse drug events were attributed to the cycling protocol. Antibiotic acquisition costs increased 31%; there was a 14.7% increase in antibiotic use. Length of stay declined by 1 day. Quarterly variability in the prevalence of vancomycin-resistant enterococci and ceftazidime resistance among combined gram-negative organisms were noted. CONCLUSIONS: Implementation of an antibiotic cycling program is feasible in a community hospital setting. No adverse safety concerns were identified. Antibiotic cycling was more expensive, partly due to an increase in antibiotic use to optimize initial empiric therapy. Quarterly antibiogram patterns suggested that antibiotic cycling may have impacted resistance, although the small number of isolates precluded statistical analysis. Further assessment of this approach is necessary to determine its relationship to antimicrobial resistance

Effects of universal masking on Massachusetts healthcare workers' COVID-19 incidence

Background: Healthcare workers (HCWs) and other essential workers are at risk of occupational infection during the COVID-19 pandemic. Several infection control strategies have been implemented. Evidence shows that universal masking can mitigate COVID-19 infection, though existing research is limited by secular trend bias. Aims: To investigate the effect of hospital universal masking on COVID-19 incidence among HCWs compared to the general population. Methods: We compared the 7-day average incidence rates between a Massachusetts (USA) healthcare system and Massachusetts residents statewide. The study period was from 17 March (the date of first incident case in the healthcare system) to 6 May (the date Massachusetts implemented public masking). The healthcare system implemented universal masking on 26 March, we allotted a 5-day lag for effect onset and peak COVID-19 incidence in Massachusetts was 20 April. Thus, we categorized 17-31 March as the pre-intervention phase, 1-20 April the intervention phase and 21 April to 6 May the epidemic decline phase. Temporal incidence trends (i.e. 7-day average slopes) were compared using standardized coefficients from linear regression models. Results: The standardized coefficients were similar between the healthcare system and the state in both the pre-intervention and epidemic decline phases. During the intervention phase, the healthcare system's epidemic slope became negative (standardized β:-0.68, 95% CI:-1.06 to-0.31), while Massachusetts' slope remained positive (standardized β: 0.99, 95% CI: 0.94 to 1.05). Conclusions: Universal masking was associated with a decreasing COVID-19 incidence trend among HCWs, while the infection rate continued to rise in the surrounding community

Sociodemographic risk factors for coronavirus disease 2019 (COVID-19) infection among Massachusetts healthcare workers: A retrospective cohort study

Objective: To better understand coronavirus disease 2019 (COVID-19) transmission among healthcare workers (HCWs), we investigated occupational and nonoccupational risk factors associated with cumulative COVID-19 incidence among a Massachusetts HCW cohort. Design, setting, and participants: The retrospective cohort study included adult HCWs in a single healthcare system from March 9 to June 3, 2020. Methods: The SARS-CoV-2 nasopharyngeal RT-PCR results and demographics of the study participants were deidentified and extracted from an established occupational health, COVID-19 database at the healthcare system. HCWs from each particular job grouping had been categorized into frontline or nonfrontline workers. Incidence rate ratios (IRRs) and odds ratios (ORs) were used to compare subgroups after excluding HCWs involved in early infection clusters before universal masking began. A sensitivity analysis was performed comparing jobs with the greatest potential occupational risks with others. Results: Of 5,177 HCWs, 152 (2.94%) were diagnosed with COVID-19. Affected HCWs resided in areas with higher community attack rates (median, 1,755.2 vs 1,412.4 cases per 100,000; P < .001; multivariate-adjusted IRR, 1.89; 95% CI, 1.03–3.44 comparing fifth to first quintile of community rates). After multivariate adjustment, African-American and Hispanic HCWs had higher incidence of COVID-19 than non- Hispanic white HCWs (IRR, 2.78; 95% CI, 1.78–4.33; and IRR, 2.41, 95% CI, 1.42–4.07, respectively). After adjusting for race and residential rates, frontline HCWs had a higher IRR (1.73, 95% CI, 1.16–2.54) than nonfrontline HCWs overall, but not within specific job categories nor when comparing the highest risk jobs to others. Conclusions: After universal masking was instituted, the strongest risk factors associated with HCW COVID-19 infection were residential community infection rate and race