Faculty Bibliography

BACKGROUND:Healthcare is responsible for 8.5% of greenhouse gas emission in the United States. Physicians are becoming increasingly concerned about the climate crisis, particularly in the field of ophthalmology where there is a growing body of literature related to sustainability. Although emissions of cataracts surgery, one of the most performed surgical procedures in the world, have been quantified, modifications to practice have yet to be made. This study aims to uplift the perspectives of a diverse set of healthcare workers on implementing environmentally sustainable practices in the cataract surgery setting. METHODS:16 semi-structured interviews were conducted with professionals working in various direct patient care or administrative roles at a large health center to gain insight on implementing a variety of sustainability initiatives. We focused on initiatives related to supply reduction, reusable supplies, multi-dosing pharmaceuticals, and health system process and policy shifts. RESULTS:Participants most frequently identified infection prevention and control (IPC) concerns as a primary barrier to implementation. Additionally, the IPC department was most often cited as a key stakeholder in implementation. However, participants from this department did not share these same concerns. Additionally, participants most often cited that these initiatives would be successfully implemented by those providing direct patient care. CONCLUSIONS:Themes generated from the collection of responses underscore a broader discussion of disconnect between policy and practice in healthcare as a barrier to implementation of these initiatives and an opportunity in harnessing clinically led change to implement sustainable practices in a growing healthcare system.

Rapid molecular assays guiding treatment of methicillin-resistant Staphylococcus aureus (MRSA) detect SCCmec (Xpert) or the SCCmec-orfX junction (BCID2). Sequence variation in this region can disrupt primer binding, yielding false-negative results. Investigation of a missed bloodstream infection linked escape to a CRISPR-Cas-associated SCCmec variant, leading to identification of 64 variants from 45 patients-2% of 2,432 screened. Misdiagnosis was restricted to clonal complex 5, a hospital-associated lineage; 11 of 40 SCCmec/junctions evaded detection by BCID2 or Xpert. Variants had mecA instability and circulated in healthcare settings. Our findings reveal a unique escape mechanism and underscore a threat to diagnostic accuracy.

UNLABELLED:isolates with low intrinsic virulence. IMPORTANCE/OBJECTIVE:infection.

BACKGROUND:infection (CDI) in patients requiring concomitant systemic antibiotics. OBJECTIVES/OBJECTIVE:To evaluate prescribing practices of vancomycin for CDI in patients that required concurrent systemic antibiotics and to determine whether a prolonged duration of vancomycin (>14 days), compared to a standard duration (10-14 days), decreased CDI recurrence. METHODS:(VRE). RESULTS:= .083) were not significantly different between groups. Discontinuation of vancomycin prior to completion of antibiotics was an independent predictor of 8-week recurrence on multivariable logistic regression (OR, 4.8; 95% CI, 1.3-18.1). CONCLUSIONS:Oral vancomycin prescribing relative to the systemic antibiotic end date may affect CDI recurrence to a greater extent than total vancomycin duration alone. Further studies are needed to confirm these findings.

TOPIC/OBJECTIVE:Understanding approaches to sustainability in cataract surgery and their risks and benefits CLINICAL RELEVANCE: In the United States, healthcare is responsible for approximately 8.5% of greenhouse gas (GHG), and cataract surgery is one of the most commonly performed surgical procedures. Ophthalmologists can contribute to reducing GHG emissions, which lead to a steadily increasing list of health concerns ranging from trauma to food instability. METHODS:We conducted a literature review to identify the benefits and risks of sustainability interventions. We then organized these interventions into a decision tree for use by individual surgeons. RESULTS:Identified sustainability interventions fall into the domains of advocacy and education, pharmaceuticals, process, and supplies and waste. Existing literature shows certain interventions may be safe, cost-effective, and environmentally friendly. These include dispensing medications home to patients after surgery, multi-dosing appropriate medications, training staff to properly sort medical waste, reducing the number of supplies used during surgery, and implementing immediate sequential bilateral cataract surgery where clinically appropriate. The literature was lacking on the benefits or risks for some interventions, such as switching specific single use supplies to reusables or implementing a hub-and-spoke style theatre setup. Many of the advocacy and education interventions have inadequate literature specific to ophthalmology but are likely to have minimal risks. CONCLUSIONS:Ophthalmologists can engage in a variety of safe and effective approaches to reduce or eliminate dangerous GHG emissions associated with cataract surgery.

BACKGROUND/UNASSIGNED: METHODS/UNASSIGNED:infections. The primary composite endpoint included escalation to intensive care unit, infection- or treatment-related readmission, mortality, and infection recurrence. Outcomes were compared between groups who received carbapenem (CG) versus carbapenem-sparing agents (CSG) as targeted gram-negative therapy. RESULTS/UNASSIGNED:= .001), while treatment with carbapenem-sparing therapy was not. CONCLUSIONS/UNASSIGNED:Our study did not find improved clinical outcomes with targeted carbapenem therapy for TZP-NS/CRO-S infections. Carbapenem-sparing agents may be considered to spare carbapenems in noncritically ill patients similar to those included in our cohort.

During the start of the COVID-19 pandemic, shortages of personal protective equipment (PPE) necessitated unprecedented and non-validated approaches to conserve PPE at healthcare facilities, especially in high income countries where single-use disposable PPE was ubiquitous. Our team conducted a systematic literature review to evaluate historic approaches for conserving single-use PPE, expecting that lower-income countries or developing contexts may already be uniquely conserving PPE. However, of the 50 included studies, only 3 originated from middle-income countries and none originated from low-income countries. Data from the included studies suggest PPE remained effective with extended use and with multiple or repeated use in clinical settings, as long as donning and doffing were performed in a standard manner. Multiple decontamination techniques were effective in disinfecting single use PPE for repeated use. These findings can inform healthcare facilities and providers in establishing protocols for safe conservation of PPE supplies and updating existing protocols to improve sustainability and overall resilience. Future studies should evaluate conservation practices in low-resource settings during non-pandemic times to develop strategies for more sustainable and resilient healthcare worldwide.

New mutations conferring resistance to SARS-CoV-2 therapeutics have important clinical implications. We describe the first cases of an independently acquired V792I RNA-dependent RNA polymerase mutation developing in renal transplant recipients after remdesivir exposure. Our work underscores the need for augmented efforts to identify concerning mutations and address their clinical implications.

Background. Staphylococcus aureus is a common cause of healthcare associated infections and is associated with high mortality. Universal S. aureus decolonization reduces methicillin-resistant S. aureus (MRSA) and other bloodstream infections among ICU patients. However, universal decolonization in acute care settings has not shown a similar benefit. We describe a screening and targeted decolonization protocol implemented at an academic hospital across acute and intensive care settings. The goal of this study was to assess the impact of decolonization on rates of S. aureus invasive infections. Methods. Adult Medicine, Oncology, Transplant, and ICU patients were screened by nasal swab for S. aureus colonization on admission and change in level of care. Colonized patients received 5 days of chlorhexidine 2% applied to the body and mupirocin for the nares. We compared decolonized patients with patients who received no decolonization. The primary outcome was S. aureus invasive infection from hospital day 5 until discharge, defined by positive cultures from sterile sites. Secondary outcomes included 30-day readmission and 30-day mortality. Results. Between 2018-2020, 3,835 (23%) out of 16,467 hospitalized patients screened positive for MSSA (74%) or MRSA (26%). Among colonized patients, median age was 67 years (interquartile range [IQR] 54-79) and median LOS was 6 days (IQR 4-11). Among patients with LOS >= 5 days, 977 (37%) received decolonization. There were 122 invasive infections, 56 (46%) occurring in patients who received decolonization. Wound infections were most common (28; 23%), followed by bacteremia (27; 22%). In multivariate regression analysis controlling for confounding factors including comorbidities and length of stay, decolonization was not significantly associated with incident invasive infections (p = 0.395). Conclusion. We report on a S. aureus screening and targeted decolonization program; our initial analyses do not demonstrate an association between decolonization and reduced invasive S. aureus infections. Further investigations will examine subsets of high-risk patients and transmission events to assess if specific populations may benefit from this program