SOURCE: Oladapo-Shittu O, Hannum SM, Salinas AB, et al. The need to expand the infection prevention workforce in home infusion therapy. Am J Infect Control 2022;00:1-3.
The increased use of outpatient infusion therapy is an enormous boon to patients, resulting in fewer days of hospitalization and a lower risk of nosocomial Clostridioides difficile infection, especially with home antimicrobial therapy. Outpatient infusion therapy may be accomplished through infusion centers or through the home with the assistance of home infusion companies. Some of these companies may be independent or affiliated with hospitals or academic institutions. However, presently there is no mandate to monitor or report outpatient central line-associated bloodstream infection (CLABSI), and most outpatient facilities and home care companies lack the ability or the appropriate staffing to do so. As a result, the true rate of outpatient CLABSI and possible resulting rehospitalization is not really known. Various reports place home CLABSI rates at anywhere from 0.22 to 1.18 per 1,000 central line days.
This article examined potential barriers for CLABSI surveillance in the outpatient setting by interviewing staff members at five large outpatient home infusion therapy (HIT) agencies. The five agencies served a large area of the East Coast, spread over 13 states and Washington, D.C. All five were not-for-profit agencies and affiliated with academic centers. A total of 21 interviews were conducted, with a minimum of two individuals from each agency. Most of the HIT agency staff were nurses (86%).
The survey found that no formal CLABSI surveillance was being conducted at any of the five agencies. None of the staff had education or training in the assessment of CLABSI, and their orientation did not include discussion of CLABSI. Most of the staff learned about CLABSI “on the job” or by the “seat of their pants.” Case recognition was “hit or miss” and largely the result of subsequent hospitalization and physician diagnosis, only if the event was recognized in discharge notes or notes from the physician, not on formal case definitions. Most staff were unaware there was a formal case definition or professional development resources, and they lacked resources, such as online toolkits or learning modules.
Barriers to monitoring and reporting CLABSI could be surmounted by:
• Developing a formal surveillance and reporting system for outpatient CLABSI;
• Mandating CLABSI reporting by HIT companies and infusion centers, with auditing;
• Providing standardized training and course materials, such as online toolkits with learning modules and key teaching points, and perhaps examples;
• Requiring HIT to provide some kind of infection prevention expertise and certification for at least one of their staff;
• Making the current case definition and guidelines easier to interpret and apply.
For-profit HIT agencies may differ from those affiliated with academic centers, with different staff recruitment and training, even less access to hospital data and physician records, as well as different workloads and time pressures. Further, if pressure is applied to HIT agencies to decrease their reported rate of CLABSI, they may be disincentivized to accept certain cases, perceived to be at higher risk for infection.
Before we can expect staff at HIT agencies to report CLABSI, public health authorities must work to simplify the current guidance and case definition. The current National Healthcare Safety Network (NHSN) CLABSI case definition, as outlined in their revised Devised Associated Module, is a mess, and I do not see how ordinary hospital or outpatient infusion staff can appropriately implement this document. The module goes into great lengths to define bloodstream infections, with a sub-definition of mucosal barrier injury laboratory-confirmed bloodstream infection (MBI-LCBI), presumably in an attempt to create a series of rules that are appropriately inclusive. The result is they have swung way too far, and the current case definition artifactually creates device-related infections where none exist.
Most of our current hospital-defined CLABSI are not true CLABSI, the infectious disease consultants involved in the care of these patients did not recognize them as such, they were not treated as such, and the devices were not removed, as would often be required with a true CLABSI (simply because a secondary source cannot be defined, at least microbiologically, which is more often the case than not). Basically, anyone with a bloodstream infection who happens to have an indwelling port or central line is at risk for being defined a CLABSI. Governing agencies have the responsibility to create regulations that achieve a valid evidence-based objective — and they should give some credence to credentialed and trained specialists.
SOURCE: Fretheim A, Elgersma IH, Helleve A, et al. Effect of wearing glasses on risk of infection with SARS-CoV-2 in the community. A randomized clinical trial. JAMA Netw Open 2022;Dec 5:e2244495.
In the hospital setting, various studies have suggested that wearing eye protection may mitigate the risk of respiratory virus transmission. However, no randomized study has clearly demonstrated a benefit from wearing glasses or eye protection, either in the hospital or the community. And yet, eye protection is considered a key element of personal protective equipment in the hospital to protect staff from SARS-CoV-2 infection.
These authors conducted a randomized controlled trial of eyeglasses in the prevention of respiratory virus and SARS-CoV-2 infection in ordinary adults in the community who do not generally wear eyeglasses. The study was conducted over a two-week period. Participants randomized to wear eyeglasses had to agree to wear glasses (regular or sunglasses) outside the home when in close contact with people or, if randomized to the control group, not to wear eyeglasses when outside the home.
The risk of confirmed COVID-19 infection was similar between the two groups (3.7% for the group wearing eyeglasses and 3.5% for the controls), and the risk of reported COVID-19 infection also was similar between the two groups (9.6% for the eyeglasses group and 11.5% for controls; relative risk [RR], 0.83; 95% confidence interval [CI], 0.82-1.0), suggesting that wearing eyeglasses made little difference in acquiring SARS-CoV-2 infection. However, the risk of respiratory illness was 30.8% for eyeglass wearers and 34.1% for controls (RR, 0.9; 95% CI, 0.82-0.99), suggesting a modest benefit from wearing eyeglasses with regard to acquiring respiratory illness. In the intervention group, 75% of participants reported wearing eyeglasses more than 50% of the time when outside their home, whereas only 10.5% of those in the control group reported wearing eyeglasses when outside the home.
Interestingly, only 39.5% of those wearing eyeglasses also wore ordinary face masks more than 50% of the time, compared with 29.7% in the control group. This study was conducted during a surge in Omicron infection in Oslo, Norway. I will keep wearing my face shield when in contact with active COVID-19 or coughing patients with acute respiratory illness.
