Persons who work closely with dairy cows, poultry, or other animals with suspected or confirmed infection with highly pathogenic avian influenza (HPAI) A(H5N1) viruses are at increased risk for infection. In September 2024, the California Department of Public Health was notified of the first human case of HPAI A(H5N1) in California through monitoring of workers on farms with infected cows. During September 30-December 24, 2024, a total of 38 persons received positive test results for HPAI A(H5N1) viruses in California; 37 were dairy farm workers with occupational exposure to sick cows, and one was a child aged <18 years with an undetermined exposure, the first pediatric HPAI A(H5N1) case reported in the United States. All patients had mild illness. The identification of cases associated with occupational exposure to HPAI A(H5N1) viruses on dairy farms highlights the continued risk for persons who work with infected animals. The pediatric case was identified through routine surveillance. Given recent increases in the prevalence of HPAI A(H5N1) viruses among some animal populations, public health agencies should continue to investigate cases of HPAI A(H5N1) in humans as part of control measures, pandemic preparedness, to identify concerning genetic changes, and to prevent and detect potential human-to-human transmission of the virus. To date, no human-to-human transmission of HPAI A(H5N1) virus has been identified in the United States.

Since the initial publication of A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals in 2008, the prevention of healthcare-associated infections (HAIs) has continued to be a national priority. Progress in healthcare epidemiology, infection prevention, antimicrobial stewardship, and implementation science research has led to improvements in our understanding of effective strategies for HAI prevention. Despite these advances, HAIs continue to affect ∼1 of every 31 hospitalized patients, leading to substantial morbidity, mortality, and excess healthcare expenditures, and persistent gaps remain between what is recommended and what is practiced.The widespread impact of the coronavirus disease 2019 (COVID-19) pandemic on HAI outcomes in acute-care hospitals has further highlighted the essential role of infection prevention programs and the critical importance of prioritizing efforts that can be sustained even in the face of resource requirements from COVID-19 and future infectious diseases crises.The Compendium: 2022 Updates document provides acute-care hospitals with up-to-date, practical expert guidance to assist in prioritizing and implementing HAI prevention efforts. It is the product of a highly collaborative effort led by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Disease Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of organizations and societies with content expertise, including the Centers for Disease Control and Prevention (CDC), the Pediatric Infectious Disease Society (PIDS), the Society for Critical Care Medicine (SCCM), the Society for Hospital Medicine (SHM), the Surgical Infection Society (SIS), and others.

Strategies to prevent catheter-associated urinary tract infections (CAUTIs) | Essential practices | Infrastructure and resources | 1 Perform a CAUTI risk assessment and implement an organization-wide program to identify and remove catheters that are no longer necessary using 1 or | more methods documented to be effective. (Quality of evidence: MODERATE) | 2 Provide appropriate infrastructure for preventing CAUTI. (Quality of evidence: LOW) | 3 Provide and implement evidence-based protocols to address multiple steps of the urinary catheter life cycle: catheter appropriateness (step 0), insertion | technique (step 1), maintenance care (step 2), and prompt removal (step 3) when no longer appropriate. (Quality of evidence: LOW) | 4 Ensure that only trained healthcare personnel (HCP) insert urinary catheters and that competency is assessed regularly. (Quality of evidence: LOW) | 5 Ensure that supplies necessary for aseptic technique for catheter insertion are available and conveniently located. (Quality of evidence: LOW) | 6 Implement a system for documenting the following in the patient record: physician order for catheter placement, indications for catheter insertion, date | and time of catheter insertion, name of individual who inserted catheter, nursing documentation of placement, daily presence of a catheter and | maintenance care tasks, and date and time of catheter removal. Record criteria for removal and justification for continued use. (Quality of evidence: | LOW) | 7 Ensure that sufficiently trained HCP and technology resources are available to support surveillance for catheter use and outcomes. (Quality of evidence: | LOW) | 8 Perform surveillance for CAUTI if indicated based on facility risk assessment or regulatory requirements. (Quality of evidence: LOW) | 9 Standardize urine culturing by adapting an institutional protocol for appropriate indications for urine cultures in patients with and without indwelling | catheters. Consider incorporating these indications into the electronic medical record, and review indications for ordering urine cultures in the CAUTI | risk assessment. (Quality of evidence: LOW) | Education and training | 1 Educate HCP involved in the insertion, care, and maintenance of urinary catheters about CAUTI prevention, including alternatives to indwelling | catheters, and procedures for catheter insertion, management, and removal. (Quality of evidence: LOW) | 2 Assess healthcare professional competency in catheter use, catheter care, and maintenance. (Quality of evidence: LOW) | 3 Educate HCP about the importance of urine-culture stewardship and provide indications for urine cultures. (Quality of evidence: LOW) | 4 Provide training on appropriate collection of urine. Specimens should be collected and should arrive at the microbiology laboratory as soon as possible, | preferably within an hour. If delay in transport to the laboratory is expected, samples should be refrigerated (no more than 24 hours) or collected in | preservative urine transport tubes. (Quality of evidence: LOW) | 5 Train clinicians to consider other methods for bladder management, such as intermittent catheterization or external male or female collection devices, | when appropriate, before placing an indwelling urethral catheter. (Quality of evidence: LOW) | 6 Share data in a timely fashion and report to appropriate stakeholders. (Quality of evidence: LOW) | Insertion of indwelling catheters | 1 Insert urinary catheters only when necessary for patient care and leave in place only as long as indications remain. (Quality of evidence: MODERATE) | 2 Consider other methods for bladder management such as intermittent catheterization, or external male or female collection devices, when appropriate. | (Quality of evidence: LOW) | 3 Use appropriate technique for catheter insertion. (Quality of evidence: MODERATE). | 4 Consider working in pairs to help perform patient positioning and monitor for potential contamination during placement. (Quality of evidence: LOW) | 5 Practice hand hygiene (based on CDC or WHO guidelines) immediately before insertion of the catheter and before and after any manipulation of the | catheter site or apparatus. (Quality of evidence: LOW) | 6 Insert catheters following aseptic technique and using sterile equipment. (Quality of evidence: LOW) | 7 Use sterile gloves, drape, and sponges, a sterile antiseptic solution for cleaning the urethral meatus, and a sterile single-use packet of lubricant jelly for | insertion. (Quality of evidence: LOW) | 8 Use a catheter with the smallest feasible diameter consistent with proper drainage to minimize urethral trauma but consider other catheter types and | sizes when warranted for patients with anticipated difficult catheterization to reduce the likelihood that a patient will experience multiple, sometimes | traumatic, catheterization attempts. (Quality of evidence: LOW) | Management of indwelling catheters | 1 Properly secure indwelling catheters after insertion to prevent movement and urethral traction. (Quality of evidence: LOW) | 2 Maintain a sterile, continuously closed drainage system. (Quality of evidence: LOW) | 3 Replace the catheter and the collecting system using aseptic technique when breaks in aseptic technique, disconnection, or leakage occur. (Quality of | evidence: LOW) | 4 For examination of fresh urine, collect a small sample by aspirating urine from the needleless sampling port with a sterile syringe/cannula adaptor after | cleansing the port with disinfectant. (Quality of evidence: LOW) | (Continued) | 2 Deborah S. Yokoe et al | https://doi.org/10.1017/ice.2023.138 Published online by Cambridge University Press | Strategies to prevent central-line–associated bloodstream infections (CLABSIs) | (Continued ) | 5 Facilitate timely transport of urine samples to laboratory. If timely transport is not feasible, consider refrigerating urine samples or using samplecollection cups with preservatives. Obtain larger volumes of urine for special analyses (eg, 24-hour urine) aseptically from the drainage bag. (Quality of | evidence: LOW) | 6 Maintain unobstructed urine flow. (Quality of evidence: LOW) | 7 Employ routine hygiene. Cleaning the meatal area with antiseptic solutions is an unresolved issue, though emerging literature supports chlorhexidine | use prior to catheter insertion. Alcohol-based products should be avoided given concerns about the alcohol causing drying of the mucosal tissues. | (Quality of evidence: LOW) | Additional approaches | 1 Develop a protocol for standardizing diagnosis and management of postoperative urinary retention, including nurse-directed use of intermittent | catheterization and use of bladder scanners when appropriate as alternatives to indwelling urethral catheterization. (Quality of evidence: MODERATE) | 2 Establish a system for analyzing and reporting data on catheter use and adverse events from catheter use. (Quality of evidence: LOW) | 3 Establish a system for defining, analyzing, and reporting data on non–catheter-associated UTIs, particularly UTIs associated with the use of devices | being used as alternatives to indwelling urethral catheters. (Quality of evidence: LOW) | Essential practices | Before insertion | 1 Provide easy access to an evidence-based list of indications for CVC use to minimize unnecessary CVC placement. (Quality of evidence: LOW) | 2 Require education and competency assessment of healthcare personnel (HCP) involved in insertion, care and maintenance of CVCs about CLABSI | prevention. (Quality of evidence: MODERATE) | 3 Bathe ICU patients aged >2 months with a chlorhexidine preparation on a daily basis. (Quality of evidence: HIGH) | At insertion | 1 In ICU and non-ICU settings, a facility should have a process in place, such as a checklist, to ensure adherence to infection prevention practices at the | time of CVC insertion. (Quality of evidence: MODERATE) | 2 Perform hand hygiene prior to catheter insertion or manipulation. (Quality of evidence: MODERATE) | 3 The subclavian site is preferred to reduce infectious complications when the catheter is placed in the ICU setting. (Quality of evidence: HIGH) | 4 Use an all-inclusive catheter cart or kit. (Quality of evidence: MODERATE) | 5 Use ultrasound guidance for catheter insertion. (Quality of evidence: HIGH) | 6 Use maximum sterile barrier precautions during CVC insertion. (Quality of evidence: MODERATE) | After insertion | 1 Ensure appropriate nurse-to-patient ratio and limit use of float nurses in ICUs. (Quality of evidence: HIGH) | 2 Use chlorhexidine-containing dressings for CVCs in patients aged >2 months. (Quality of evidence: HIGH) | 3 For nontunneled CVCs in adults and children, change transparent dressings and perform site care with a chlorhexidine-based antiseptic at least every 7 | days or immediately if the dressing is soiled, loose, or damp. Change gauze dressings every 2 days or earlier if the dressing is soiled, loose, or damp. | (Quality of evidence: MODERATE) | 4 Disinfect catheter hubs, needleless connectors, and injection ports before accessing the catheter. (Quality of evidence: MODERATE) | 5 Remove nonessential catheters. (Quality of evidence: MODERATE) | 6 Routine replacement of administration sets not used for blood, blood products, or lipid formulations can be performed at intervals up to 7 days. | (Quality of evidence: HIGH) | 7 Perform surveillance for CLABSI in ICU and non-ICU settings. (Quality of evidence: HIGH) | Additional approaches | 1 Use antiseptic or antimicrobial-impregnated CVCs. (Quality of evidence: HIGH in adult patients; MODERATE in pediatric patients) | 2 Use antimicrobial lock therapy for long-term CVCs. (Quality of evidence: HIGH) | 3 Use recombinant tissue plasminogen activating factor (rt-PA) once weekly after hemodialysis in patients undergoing hemodialysis through a CVC. | (Quality of evidence: HIGH) | 4 Utilize infusion or vascular access teams for reducing CLABSI rates. (Quality of evidence: LOW) | 5 Use antimicrobial ointments for hemodialysis catheter-insertion sites. (Quality of evidence: HIGH) | 6 Use an antiseptic-containing hub, connector cap, or port protector to cover connectors. (Quality of evidence: MODERATE) | Infection Control & Hospital Epidemiology 3 | https://doi.org/10.1017/ice.2023.138 Published online by Cambridge University Press | Strategies to prevent Clostridioides difficile infections (CDIs) | Strategies to prevent methicillin-resistant Staphylococcus aureus (MRSA) transmission and infection | Essential practices | 1 Encourage appropriate use of antimicrobials through implementation of an antimicrobial stewardship program. (Quality of evidence: MODERATE) | 2 Implement diagnostic stewardship practices for ensuring appropriate use and interpretation of C. difficile testing. (Quality of evidence: LOW) | 3 Use contact precautions for infected patients, single-patient room preferred. (Quality of evidence: LOW for hand hygiene; MODERATE for gloves; LOW | for gowns; LOW for single-patient room) | 4 Adequately clean and disinfect equipment and the environment of patients with CDI. (Quality of evidence: LOW for equipment; LOW for environment) | 5 Assess the adequacy of room cleaning. (Quality of evidence: LOW) | 6 Implement a laboratory-based alert system to provide immediate notification to infection preventionists and clinical personnel about newly diagnosed | patients with CDI. (Quality of evidence: LOW) | 7 Conduct CDI surveillance and analyze and report CDI data. (Quality of evidence: LOW) | 8 Educate healthcare personnel (HCP), environmental service personnel, and hospital administration about CDI. (Quality of evidence: LOW) | 9 Educate patients and their families about CDI as appropriate. (Quality of evidence: LOW) | 10 Measure compliance with CDC or WHO hand hygiene and contact precaution recommendations. (Quality of evidence: LOW) | Additional approaches | 1 Intensify the assessment of compliance with process measures. (Quality of evidence: LOW) | 2 Perform hand hygiene with soap and water as the preferred method following care of or interacting with the healthcare environment of a patient with | CDI. (Quality of evidence: LOW) | 3 Place patients with diarrhea on contact precautions while C. difficile testing is pending. (Quality of evidence: LOW) | 4 Prolong the duration of contact precautions after the patient becomes asymptomatic until hospital discharge. (Quality of evidence: LOW) | 5 Use an EPA-approved sporicidal disinfectant, such as diluted (1:10) sodium hypochlorite, for environmental cleaning and disinfection. Implement a | system to coordinate with environmental services if it is determined that sodium hypochlorite is needed for environmental disinfection. (Quality of | evidence: LOW) | Essential practices | 1 Implement an MRSA monitoring program. (Quality of evidence: LOW) | 2 Conduct an MRSA risk assessment. (Quality of evidence: LOW) | 3 Promote compliance with CDC or World Health Organization (WHO) hand hygiene recommendations. (Quality of evidence: MODERATE) | 4 Use contact precautions for MRSA-colonized and MRSA-infected patients. A facility that chooses or has already chosen to modify the use of contact | precautions for some or all of these patients should conduct an MRSA-specific risk assessment to evaluate the facility for transmission risks and to | assess the effectiveness of other MRSA risk mitigation strategies (eg, hand hygiene, cleaning and disinfection of the environment, single occupancy | patient rooms) and should establish a process for ongoing monitoring, oversight, and risk assessment. (Quality of evidence: MODERATE) | 5 Ensure cleaning and disinfection of equipment and the environment. (Quality of evidence: MODERATE) | 6 Implement a laboratory-based alert system that notifies healthcare personnel (HCP) of new MRSA-colonized or MRSA-infected patients in a timely | manner. (Quality of evidence: LOW) | 7 Implement an alert system that identifies readmitted or transferred MRSA-colonized or MRSA-infected patients. (Quality of evidence: LOW) | 8 Provide MRSA data and outcome measures to key stakeholders, including senior leadership, physicians, nursing staff, and others. (Quality of evidence: | LOW) | 9 Educate healthcare personnel about MRSA. (Quality of evidence: LOW) | 10 Educate patients and families about MRSA. (Quality of evidence: LOW) | 11 Implement an antimicrobial stewardship program. (Quality of evidence: LOW) | Additional approaches | Active surveillance testing (AST) | 1 Implement an MRSA AST program for select patient populations as part of a multifaceted strategy to control and prevent MRSA. (Quality of evidence: | MODERATE) Note: specific populations may have different evidence ratings. | 2 Active surveillance for MRSA in conjunction with decolonization can be performed in targeted populations prior to surgery to prevent postsurgical | MRSA infection. (Quality of evidence: MODERATE) | (Continued) | 4 Deborah S. Yokoe et al | https://doi.org/10.1017/ice.2023.138 Published online by Cambridge University Press | Strategies to prevent surgical-site infections (SSIs) | (Continued ) | 3 Active surveillance with contact precautions is inferior to universal decolonization for reduction of MRSA clinical isolates in adult ICUs. (Quality of | evidence: HIGH) | 4 Hospital-wide active surveillance for MRSA can be used in conjunction with contact precautions to reduce the incidence of MRSA infection. (Quality of | evidence: MODERATE) | 5 Active surveillance can be performed in the setting of an MRSA outbreak or evidence of ongoing transmission of MRSA within a unit as part of a | multifaceted strategy to halt transmission. (Quality of evidence: MODERATE) | Screen healthcare personnel for MRSA infection or colonization | 1 Screen HCP for MRSA infection or colonization if they are epidemiologically linked to a cluster of MRSA infections. (Quality of evidence: LOW) | MRSA decolonization therapy | 1 Use universal decolonization (ie, daily CHG bathing plus 5 days of nasal decolonization) for all patients in adult ICUs to reduce endemic MRSA clinical | cultures. (Quality of evidence: HIGH) | 2 Perform preoperative nares screening with targeted use of CHG and nasal decolonization in MRSA carriers to reduce MRSA SSI from surgical | procedures involving implantation of hardware. (Quality of evidence: MODERATE) | 3 Screen for MRSA and provide targeted decolonization with CHG bathing and nasal decolonization to MRSA carriers in surgical units to reduce | postoperative MRSA inpatient infections. (Quality of evidence: MODERATE) | 4 Provide CHG bathing plus nasal decolonization to known MRSA carriers outside the ICU with medical devices, specifically central lines, midline | catheters, and lumbar drains to reduce MRSA clinical cultures. (Quality of evidence: MODERATE) | 5 Consider postdischarge decolonization of MRSA carriers to reduce postdischarge MRSA infections and readmissions. (Quality of evidence: HIGH) | 6 Neonatal ICUs should consider targeted or universal decolonization during times of above-average MRSA infection rates or targeted decolonization for | patients at high risk of MRSA infection (eg, low birth weight, indwelling devices, or prior to high-risk surgeries). (Quality of evidence: MODERATE) | 7 Burn units should consider targeted or universal decolonization during times of above-average MRSA infection rates. (Quality of evidence: MODERATE) | 8 Consider targeted or universal decolonization of hemodialysis patients. (Quality of evidence: MODERATE) | 9 Decolonization should be strongly considered as part of a multimodal approach to control MRSA outbreaks. (Quality of evidence: MODERATE) | Universal use of gowns and gloves | 1 Use gowns and gloves when providing care to or entering the room of any adult ICU patient, regardless of MRSA colonization status. (Quality of | evidence: MODERATE) | Essential practices | 1 Administer antimicrobial prophylaxis according to evidence-based standards and guidelines. (Quality of evidence: HIGH) | 2 Use a combination of parenteral and oral antimicrobial prophylaxis prior to elective colorectal surgery to reduce the risk of SSI. (Quality of evidence: | HIGH) | 3 Decolonize surgical patients with an anti-staphylococcal agent in the preoperative setting for orthopedic and cardiothoracic procedures. (Quality of | evidence: HIGH) | Decolonize surgical patients in other procedures at high risk of staphylococcal SSI, such as those involving prosthetic material. (Quality of evidence: | LOW) | 4 Use antiseptic-containing preoperative vaginal preparation agents for patients undergoing cesarean delivery or hysterectomy. (Quality of evidence: | MODERATE) | 5 Do not remove hair at the operative site unless the presence of hair will interfere with the surgical procedure. (Quality of evidence: MODERATE) | 6 Use alcohol-containing preoperative skin preparatory agents in combination with an antiseptic. (Quality of evidence: HIGH) | 7 For procedures not requiring hypothermia, maintain normothermia (temperature >35.5 °C) during the perioperative period. (Quality of evidence: HIGH). | 8 Use impervious plastic wound protectors for gastrointestinal and biliary tract surgery. (Quality of evidence: HIGH) | 9 Perform intraoperative antiseptic wound lavage. (Quality of evidence: MODERATE) | 10 Control blood glucose level during the immediate postoperative period for all patients. (Quality of evidence: HIGH) | 11 Use a checklist and/or bundle to ensure compliance with best practices to improve surgical patient safety. (Quality of evidence: HIGH) | 12 Perform surveillance for SSI. (Quality of evidence: MODERATE) | 13 Increase the efficiency of surveillance by utilizing automated data. (Quality of evidence: MODERATE) | 14 Provide ongoing SSI rate feedback to surgical and perioperative personnel and leadership. (Quality of evidence: MODERATE) | 15 Measure and provide feedback to healthcare personnel (HCP) regarding rates of compliance with process measures. (Quality of evidence: LOW) | (Continued) | Infection Control & Hospital Epidemiology 5 | https://doi.org/10.1017/ice.2023.138 Published online by Cambridge University Press | Strategies to prevent ventilator-associated pneumonia (VAP) and ventilator-associated events (VAEs) | Adult patients | (Continued ) | 16 Educate surgeons and perioperative personnel about SSI prevention measures. (Quality of evidence: LOW) | 17 Educate patients and their families about SSI prevention as appropriate. (Quality of evidence: LOW) | 18 Implement policies and practices to reduce the risk of SSI for patients that align with applicable evidence-based standards, rules and regulations, and | medical device manufacturer instructions for use. (Quality of evidence: MODERATE) | 19 Observe and review operating room personnel and the environment of care in the operating room and in central sterile reprocessing. (Quality of | evidence: LOW) | Additional approaches | 1 Perform an SSI risk assessment. (Quality of evidence: LOW) | 2 Consider use of negative-pressure dressings in patients who may benefit. (Quality of evidence: MODERATE) | 3 Observe and review practices in the preoperative clinic, post-anesthesia care unit, surgical intensive care unit, and/or surgical ward. (Quality of | evidence: MODERATE) | 4 Use antiseptic-impregnated sutures as a strategy to prevent SSI. (Quality of evidence: MODERATE) | Essential practices | Interventions with little risk of harm and that are associated with decreases in duration of mechanical ventilation, length of stay, mortality, antibiotic utilization, | and/or costs | Avoid intubation and prevent reintubation if possible. | 1 Use high flow nasal oxygen or non-invasive positive pressure ventilation (NIPPV) as appropriate, whenever safe and feasible. (Quality of evidence: HIGH) | Minimize sedation. | 1 Minimize sedation of ventilated patients whenever possible. (Quality of evidence: HIGH) | 2 Preferentially use multimodal strategies and medications other than benzodiazepines to manage agitation. (Quality of evidence: HIGH) | 3 Utilize a protocol to minimize sedation. (Quality of evidence: HIGH) | 4 Implement a ventilator liberation protocol. (Quality of evidence: HIGH) | Maintain and improve physical conditioning. | 1 Provide early exercise and mobilization. (Quality of evidence: MODERATE) | Elevate the head of the bed to 30°–45°. (Quality of evidence: LOW) | Provide oral care with toothbrushing but without chlorhexidine. (Quality of evidence: MODERATE) | Provide early enteral rather than parenteral nutrition. (Quality of evidence: HIGH) | Maintain ventilator circuits. | 1 Change the ventilator circuit only if visibly soiled or malfunctioning (or per manufacturers’ instructions) (Quality of evidence: HIGH). | Additional approaches | May decrease duration of mechanical ventilation, length of stay, and/or mortality in some populations but not in others, and they may confer some risk of harm | in some populations. | 1 Consider using selective decontamination of the oropharynx and digestive tract to decrease microbial burden in ICUs with low prevalence of antibiotic | resistant organisms. Antimicrobial decontamination is not recommended in countries, regions, or ICUs with high prevalence of antibiotic-resistant | organisms. (Quality of evidence: HIGH) | Additional approaches | May lower VAP rates, but current data are insufficient to determine their impact on duration of mechanical ventilation, length of stay, and mortality. | 1 Consider using endotracheal tubes with subglottic secretion drainage ports to minimize pooling of secretions above the endotracheal cuff in patients | likely to require >48–72 hours of intubation. (Quality of evidence: MODERATE) | 2 Consider early tracheostomy. (Quality of evidence: MODERATE) | 3 Consider postpyloric feeding tube placement in patients with gastric feeding intolerance at high risk for aspiration. (Quality of evidence: MODERATE) | 6 Deborah S. Yokoe et al | https://doi.org/10.1017/ice.2023.138 Published online by Cambridge University Press | Preterm neonatal patients | Pediatric patients | Essential practices | Confer minimal risk of harm and may lower VAP and/or PedVAE rates. | Avoid intubation. (Quality of evidence: HIGH) | Minimize duration of mechanical ventilation. (Quality of evidence: HIGH) | 1 Manage patients without sedation whenever possible. (Quality of evidence: LOW) | 2 Use caffeine therapy for apnea of prematurity within 72 hours after birth to facilitate extubation. (Quality of evidence: HIGH) | 3 Assess readiness to extubate daily. (Quality of evidence: LOW) | 4 Take steps to minimize unplanned extubation and reintubation. (Quality of evidence: LOW) | 5 Provide regular oral care with sterile water (extrapolated from practice in infants and children, no data in preterm neonates). (Quality of evidence: | LOW) | 6 Change the ventilator circuit only if visibly soiled or malfunctioning or according to the manufacturer’s instructions for use (extrapolated from studies in | adults and children, no data in preterm neonates). (Quality of evidence: LOW) | Additional approaches | Minimal risks of harm, but impact on VAP and VAE rates is unknown. | 1 Lateral recumbent positioning. (Quality of evidence: LOW) | 2 Reverse Trendelenberg positioning. (Quality of evidence: LOW) | 3 Closed or in-line suctioning. (Quality of evidence: LOW) | 4 Oral care with maternal colostrum. (Quality of evidence: MODERATE) | Essential practices | Confer minimal risk of harm and some data suggest that they may lower VAP rates, PedVAE rates, and/or duration of mechanical ventilation. | Avoid intubation. | 1 Use noninvasive positive pressure ventilation (NIPPV) or high-flow oxygen by nasal cannula whenever safe and feasible. (Quality of evidence: | MODERATE) | Minimize duration of mechanical ventilation. | 1 Assess readiness to extubate daily using spontaneous breathing trials in patients without contraindications. (Quality of evidence: MODERATE) | 2 Take steps to minimize unplanned extubations and reintubations. (Quality of evidence: LOW) | 3 Avoid fluid overload. (Quality of evidence: MODERATE) | Provide regular oral care (ie, toothbrushing or gauze if no teeth). (Quality of evidence: LOW) | Elevate the head of the bed unless medically contraindicated. (Quality of evidence: LOW) | Maintain ventilator circuits. | 1 Change ventilator circuits only when visibly soiled or malfunctioning (or per manufacturer’s instructions). (Quality of evidence: MODERATE) | 2 Remove condensate from the ventilator circuit frequently and avoid draining the condensate toward the patient. (Quality of evidence: LOW) | Endotracheal tube selection and management | 1 Use cuffed endotracheal tubes. (Quality of evidence: LOW) | 2 Maintain cuff pressure and volume at the minimal occlusive settings to prevent clinically significant air leaks around the endotracheal tube, typically | 20-25cm H2O. This “minimal leak” approach is associated with lower rates of post-extubation stridor. (Quality of evidence: LOW) | 3 Suction oral secretions before each position change. (Quality of evidence: LOW) | Additional approaches | Minimal risks of harm and some evidence of benefit in adult patients but data in pediatric populations are limited. | 1 Minimize sedation. (Quality of evidence: MODERATE) | 2 Use endotracheal tubes with subglottic secretion drainage ports for patients ≥10 years of age. (Quality of evidence: LOW) | 3 Consider early tracheostomy. (Quality of evidence: LOW) | Infection Control & Hospital Epidemiology 7 | https://doi.org/10.1017/ice.2023.138 Published online by Cambridge University Press | Strategies to prevent nonventilator hospital-acquired pneumonia (NV-HAP) | Strategies to prevent healthcare-associated infections through hand hygiene | Essential practices | Promote the maintenance of healthy hand skin and nails. (Quality of evidence: HIGH) | 1 Promote the preferential use of alcohol-based hand sanitizer (ABHS) in most clinical situations. (Quality of evidence: HIGH) | 2 Perform hand hygiene as indicated by CDC or the WHO Five Moments. (Quality of evidence: HIGH) | 3 Include fingernail care in facility-specific policies related to hand hygiene. (Quality of evidence: HIGH) | a) Healthcare personnel (HCP) should maintain short, natural fingernails. | b) Nails should not extend past the fingertip. | c) HCP who provide direct or indirect care in high-risk areas | (eg, ICU or perioperative) should not wear artificial fingernail extenders. | d) Prohibitions against fingernail polish (standard or gel shellac) are at the discretion of the infection prevention program, except among scrubbed | individuals who interact with the sterile field during surgical procedures; these individuals should not wear fingernail polish or gel shellac. | 4 Engage all HCP in primary prevention of occupational irritant and allergic contact dermatitis. (Quality of evidence: HIGH) | 5 Provide cotton glove liners for HCP with hand irritation and educate these HCP on their use. (Quality of evidence: MODERATE) | Select appropriate products. | 1 For routine hand hygiene, choose liquid, gel, or foam ABHS with at least 60% alcohol. (Quality of evidence: HIGH) | 2 Involve HCP in selection of products. (Quality of evidence: HIGH) | 3 Obtain and consider manufacturers’ product-specific data if seeking ABHS with ingredients that may enhance efficacy against organisms anticipated to | be less susceptible to biocides. (Quality of evidence: MODERATE) | 4 Confirm that the volume of ABHS dispensed is consistent with the volume shown to be efficacious. (Quality of evidence: HIGH) | 5 Educate HCP about an appropriate volume of ABHS and the time required to obtain effectiveness. (Quality of evidence: HIGH) | 6 Provide facility-approved hand moisturizer that is compatible with antiseptics and gloves. (Quality of evidence: HIGH) | 7 For surgical antisepsis, use an FDA-approved surgical hand scrub or waterless surgical hand rub. (Quality of evidence: HIGH) | Ensure the accessibility of hand hygiene supplies. (Quality of evidence: HIGH) | 1 Ensure ABHS dispensers are unambiguous, visible, and accessible within the workflow of HCP. (Quality of evidence: HIGH) | 2 In private rooms, consider 2 ABHS dispensers the minimum threshold for adequate numbers of dispensers: 1 dispenser in the hallway, and 1 in the | patient room. (Quality of evidence: HIGH) | 3 In semiprivate rooms, suites, bays, and other multipatient bed configurations, consider 1 dispenser per 2 beds the minimum threshold for adequate | numbers of dispensers. Place ABHS dispensers in the workflow of HCP. (Quality of evidence: LOW) | 4 Ensure that the placement of hand hygiene supplies (eg, individual pocket-sized dispensers, bed mounted ABHS dispenser, single use pump bottles) is | easily accessible for HCP in all areas where patients receive care. (Quality of evidence: HIGH) | 5 Evaluate for the risk of intentional consumption. Utilize dispensers that mitigate this risk, such as wall-mounted dispensers that allow limited numbers | of activations within short periods (eg, 5 seconds). (Quality of evidence: LOW) | 6 Have surgical hand rub and scrub available in perioperative areas. (Quality of evidence: HIGH) | 7 Consider providing ABHS hand rubs or handwash with FDA-approved antiseptics for use in procedural areas and prior to high-risk bedside procedures | (eg, central-line insertion). (Quality of evidence: LOW) | (Continued) | Practices supported by interventional studies suggesting lower | NV-HAP rates | 1 Provide regular oral care. | 2 Diagnose and manage dysphagia. | 3 Provide early mobilization. | 4 Implement multimodal interventions to prevent viral infections. | 5 Use prevention bundles. | 8 Deborah S. Yokoe et al | https://doi.org/10.1017/ice.2023.138 Published online by Cambridge University Press | Implementing strategies to prevent healthcare-associated infections | Standard approach to implementation | Examples of implementation frameworks | (Continued ) | Ensure appropriate glove use to reduce hand and environmental contamination. (Quality of Evidence: HIGH) | 1 Use gloves for all contact with the patient and environment as indicated by standard and contact precautions during the care of individuals with | organisms confirmed to be less susceptible to biocides (e.g., C. difficile or norovirus) | 2 Educate HCP about the potential for self-contamination and environmental contamination when gloves are worn. (Quality of evidence: HIGH) | 3 Educate and confirm the ability of HCP to doff gloves in a manner that avoids contamination. (Quality of evidence: HIGH) | Take steps to reduce environmental contamination associated with sinks and sink drains. (Quality of evidence: HIGH) | Monitor adherence to hand hygiene. (Quality of evidence: HIGH) | Provide timely and meaningful feedback to enhance a culture of safety. (Quality of evidence: MODERATE) | Additional approaches during outbreaks | 1 Consider educating HCP using a structured approach (eg, WHO Steps) for handwashing or hand sanitizing. Evaluate HCP adherence to technique. | (Quality of evidence: LOW) | 2 For waterborne pathogens of premise plumbing, consider disinfection of sink drains using an EPA-registered disinfectant with claims against biofilms. | Consult with state or local public health for assistance in determining appropriate protocols for use and other actions needed to ensure safe supply. | (Quality of evidence: LOW) | 3 For C. difficile and norovirus, in addition to contact precautions, encourage hand washing with soap and water after the care of patients with known or | suspected infections. (Quality of evidence: LOW) | 1 Assess determinants of change and | classify as follows: | • Facilitators: promote practice or | change, or | • Barriers: hinder practice or change | Individual level: healthcare personnel, leaders, patients, and visitors’ preferences, needs, attitudes, and | knowledge. | Facility level: team composition, communication, culture, capacity, policies, resources. | Partners: degree of support and buy-in. | 2 Choose measures Measurement methods must be appropriate for the question(s) they seek to answer and adhere to the | methods’ data collection and analysis rules: | • Outcome measure: ultimate goal (eg, HAI reduction). | • Process measure: action reliability (eg, bundle adherence). | • Balancing measure: undesired outcome of change (eg, staff absences due to required vaccine side effects). | 3 Select framework(s) See below and “Implementing Strategies to Prevent Infections in Acute Care Settings” (Table 3) | 32 | Framework Published Experience Resources | 4Es Settings | • Healthcare facilities | • Large-scale projects including multiple | sites | Infection prevention and control | • HAI prevention (including mortality | reduction and cost savings) | • 4Es Framework11 | • HAI reduction12–14 | • Mortality reduction15 | • Cost savings16 | Behavior Change Wheel Settings | • Community-based practice | • Healthcare facilities | Healthy behaviors | • Smoking cessation | • Obesity prevention | • Increased physical activity | Infection prevention and control | • Hand hygiene adherence | • Antibiotic prescribing17 | • Behavior Change Wheel: A Guide to Designing Interventions18 | • Stand More at Work (SMArT Work)19 | (Continued) | Infection Control & Hospital Epidemiology 9 | https://doi.org/10.1017/ice.2023.138 Published online by Cambridge University Press | Acknowledgments. The Compendium Partners thank the authors for their | dedication to this work, including maintaining adherence to the rigorous | process for the development of the Compendium: 2022 Updates, involving but | not limited to screening of thousands of articles; achieving multilevel consensus; | and consideration of, response to, and incorporation of many organizations’ | feedback and comments. We acknowledge these efforts especially because they | occurred as the authors handled the demands of the COVID-19 pandemic. The | authors thank Valerie Deloney, MBA, for her organizational expertise in the | development of this manuscript and Janet Waters, MLS, BSN, RN, for her | expertise in developing the strategies used for the literature searches that | informed this manuscript. The authors thank the many individuals and | organizations who gave their time and expertise to review and provide | (Continued ) | Comprehensive Unit-based | Safety Program (CUSP) | Settings | • Intensive care units | • Ambulatory centers | Improvements | • Antibiotic prescribing | • CLABSI prevention | • CAUTI prevention | • CUSP Implementation Toolkit20 | • AHA/HRET: Eliminating CAUTI (Stop CAUTI)21 | • AHRQ Toolkit to Improve Safety in Ambulatory Surgery Centers22 | European Mixed Methods Settings | • European institutions of varied | healthcare systems and cultures | Improvements: | • CLABSI prevention | • Hand hygiene | • PROHIBIT: Description and Materials23 | Getting to Outcomes (GTO)® Settings | • Community programs and services | Improvements | • Sexual health promotion | • Dual-disorder treatment program in | veterans | • Community emergency preparedness | • RAND Guide for Emergency Preparedness24 (illustrated overview of GTO® methodology) | Model for Improvement Settings | • Healthcare (inpatient, perioperative, | ambulatory) | • Public health | Interventions | • PPE use | • HAI prevention | • Public health process evaluation | • Institute for Healthcare Improvement25 | • The Improvement Guide26 | • Deming’s System of Profound Knowledge27 | Reach, Effectiveness, Adoption, | Implementation, Maintenance | (RE-AIM) | Settings | • Healthcare | • Public health | • Community programs | • Sexual health | Evaluations | • Antimicrobial stewardship in the ICU | • Clinical practice guidelines for STIs | • Promotion of vaccination | • Implementation of contact tracing | • RE-AIM.org28 | • Understanding and applying the RE-AIM framework: Clarifications and | resources29 | Replicating Effective Practices | (REP) | Settings | • Healthcare | • Public health | • HIV prevention | Interventions that have produced | positive results are reframed for local | relevance | CDC Compendium of HIV Prevention Interventions with Evidence of | Effectiveness30 (see Section C, Intervention Checklist) | Theoretical Domains Settings | • Healthcare (inpatient, perioperative, | ambulatory) | • Community (individual and communitybased behaviors) | Health maintenance | • Diabetes management in primary care | • Pregnancy weight management | HCP practice | • ICU blood transfusion | • Selective GI tract decontamination | • Preoperative testing | • Spine imaging | • Hand hygiene

This document introduces and explains common implementation concepts and frameworks relevant to healthcare epidemiology and infection prevention and control and can serve as a stand-alone guide or be paired with the "SHEA/IDSA/APIC Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals: 2022 Updates," which contain technical implementation guidance for specific healthcare-associated infections. This Compendium article focuses on broad behavioral and socio-adaptive concepts and suggests ways that infection prevention and control teams, healthcare epidemiologists, infection preventionists, and specialty groups may utilize them to deliver high-quality care. Implementation concepts, frameworks, and models can help bridge the "knowing-doing" gap, a term used to describe why practices in healthcare may diverge from those recommended according to evidence. It aims to guide the reader to think about implementation and to find resources suited for a specific setting and circumstances by describing strategies for implementation, including determinants and measurement, as well as the conceptual models and frameworks: 4Es, Behavior Change Wheel, CUSP, European and Mixed Methods, Getting to Outcomes, Model for Improvement, RE-AIM, REP, and Theoretical Domains.

BACKGROUND: An association between rotavirus vaccination and intussusception has been documented in post-licensure studies in some countries. We evaluated the risk of intussusception associated with monovalent rotavirus vaccine (Rotavac) administered at 6, 10 and 14 weeks of age in India. METHODS: Active prospective surveillance for intussusception was conducted at 22 hospitals across 16 states from April 2016 through September 2017. Data on demography, clinical features and vaccination were documented. Age-adjusted relative incidence for 1-7, 8-21, and 1-21 days after rotavirus vaccination in children aged 28-364 days at intussusception onset was estimated using the self-controlled case-series (SCCS) method. Only Brighton Collaboration level 1 cases were included. RESULTS: Out of 670 children aged 2-23 months with intussusception, 311 (46.4%) children were aged 28-364 days with confirmed vaccination status. Out of these, 52 intussusception cases with confirmed receipt of RVV were included in the SCCS analysis. No intussusception case was observed within 21 days of dose 1. Only one case occurred during 8-21 days after the dose 2. Post-dose 3, two cases in 1-7 days and 7 cases during 8-21 days period were observed. There was no increased risk of intussusception during 1-7 days after the doses 1 and 2 (zero cases observed) or dose 3 (relative incidence [RI], 1.71 [95% confidence interval {CI} 0.0-5.11]). Similarly, no increased risk during 8-21 days after the dose 1 (zero cases observed), dose 2 (RI, 0.71 [95% CI, 0.0-3.28]) or dose 3 (RI, 2.52 [95% CI, 0.78-5.61]). The results were similar for 1-21 day periods after the doses separately or pooled. CONCLUSIONS: The risk of intussusception during the first 21 days after any dose of rotavirus vaccine (Rotavac) was not higher among the Indian infants than the background risk, based on limited SCCS analysis of 52 children.

OBJECTIVES: To use a standardized tool for a multicenter assessment of antibiotic appropriateness in ICUs and identify local antibiotic stewardship improvement opportunities. DESIGN: Pilot point prevalence conducted on October 5, 2016; point prevalence survey conducted on March 1, 2017. SETTING: ICUs in 12 U.S. acute care hospitals with median bed size 563. PATIENTS: Receiving antibiotics on participating units on March 1, 2017. INTERVENTIONS: The Centers for Disease Control and Prevention tool for the Assessment of Appropriateness of Inpatient Antibiotics was made actionable by an expert antibiotic stewardship panel and implemented across hospitals. Data were collected by antibiotic stewardship program personnel at each hospital, deidentified and submitted in aggregate for benchmarking. hospital personnel identified most salient reasons for inappropriate use by category and agent. MEASUREMENTS AND MAIN RESULTS: Forty-seven ICUs participated. Most hospitals (83%) identified as teaching with median licensed ICU beds of 70. On March 1, 2017, 362 (54%) of 667 ICU patients were on antibiotics (range, 8-81 patients); of these, 112 (31%) were identified as inappropriate and administered greater than 72 hours among all 12 hospitals (range, 9-82%). Prophylactic antibiotic regimens and PICU patients demonstrated a statistically significant risk ratio of 1.76 and 1.90 for inappropriate treatment, respectively. Reasons for inappropriate use included unnecessarily broad spectrum (29%), no infection or nonbacterial syndrome (22%), and duration longer than necessary (21%). Of patients on inappropriate antibiotic therapy in surgical ICUs, a statistically significant risk ratio of 2.59 was calculated for noninfectious or nonbacterial reasons for inappropriate therapy. CONCLUSIONS: In this multicenter point prevalence study, 31% of ICU antibiotic regimens were inappropriate; prophylactic regimens were often inappropriate across different ICU types, particularly in surgical ICUs. Engaging intensivists in antibiotic stewardship program efforts is crucial to sustain the efficacy of antibiotics and quality of infectious diseases care in critical care settings. This study underscores the value of standardized assessment tools and benchmarking to be shared with local leaders for targeted antibiotic stewardship program interventions.

Background: Countdown to 2030 (CD2030) tracks progress in the 81 countries that account for more than 90% of under-five child deaths and 95% of maternal deaths in the world. In 2017, CD2030 identified syphilis screening and treatment during antenatal care (ANC) as priority indicators for monitoring. Methods: Country-reported data in the UNAIDS Global AIDS Monitoring System (GAM) system were used to evaluate four key syphilis indicators from CD2030 countries: (1) maternal syphilis screening and (2) treatment coverage during ANC, (3) syphilis seroprevalence among ANC attendees, and (4) national congenital syphilis (CS) case rates. A cascade analysis for CD2030 countries with coverage data for the number of women attending at least 4 antenatal care visits (ANC4), syphilis testing, seroprevalence and treatment was performed to estimate the number of CS cases that were attributable to missed opportunities for syphilis screening and treatment during antenatal care. Results: Of 81 countries, 52 (64%) reported one or more values for CS indicators into the GAM system during 2016-2017; only 53 (65%) had maternal syphilis testing coverage, 41 (51%) had screening positivity, and 40 (49%) had treatment coverage. CS case rates were reported by 13 (16%) countries. During 2016-2017, four countries reported syphilis screening and treatment coverage of >/=95% consistent with World Health Organization (WHO) targets. Sufficient data were available for 40 (49%) of countries to construct a cascade for data years 2016 and 2017. Syphilis screening and treatment service gaps within ANC4 resulted in an estimated total of 103 648 adverse birth outcomes with 41 858 of these occurring as stillbirths among women attending ANC4 (n = 31 914 408). Women not in ANC4 (n = 25 619 784) contributed an additional 67 348 estimated adverse birth outcomes with 27 198 of these occurring as stillbirths for a total of 69 056 preventable stillbirths attributable to syphilis in these 40 countries. Conclusion: These data and findings can serve as an initial baseline evaluation of antenatal syphilis surveillance and service coverage and can be used to guide improvement of delivery and monitoring of syphilis screening and treatment in ANC for these priority countries.

On October 25, 2018, at 2:15 a.m., a woman aged 30 years and her mother, aged 55 years, both of Egyptian descent, arrived at an emergency department in New Jersey in hypotensive shock after 16 hours of abdominal pain, vomiting, and diarrhea. The daughter also reported blurry vision and double vision (diplopia), shortness of breath, chest pain, and difficulty speaking. She appeared lethargic and had ophthalmoplegia and bilateral ptosis. Both women were admitted to the hospital. The mother improved after fluid resuscitation, but the daughter required vasopressor support in the intensive care unit. Although the mother did not have evidence of cranial nerve involvement on admission, during the next 24 hours, she developed dysphagia and autonomic dysfunction with syncope and orthostasis and was transferred to the intensive care unit as her symptoms progressively worsened similar to those of her daughter.

Middle East respiratory syndrome coronavirus (MERS-CoV) shedding and antibody responses are not fully understood, particularly in relation to underlying medical conditions, clinical manifestations, and mortality. We enrolled MERS-CoV-positive patients at a hospital in Saudi Arabia and periodically collected specimens from multiple sites for real-time reverse transcription PCR and serologic testing. We conducted interviews and chart abstractions to collect clinical, epidemiologic, and laboratory information. We found that diabetes mellitus among survivors was associated with prolonged MERS-CoV RNA detection in the respiratory tract. Among case-patients who died, development of robust neutralizing serum antibody responses during the second and third week of illness was not sufficient for patient recovery or virus clearance. Fever and cough among mildly ill patients typically aligned with RNA detection in the upper respiratory tract; RNA levels peaked during the first week of illness. These findings should be considered in the development of infection control policies, vaccines, and antibody therapeutics.

Camel contact is a recognized risk factor for Middle East respiratory syndrome coronavirus (MERS-CoV) infection. Because specific camel exposures associated with MERS-CoV seropositivity are not fully understood, we investigated worker-camel interactions and MERS-CoV seroprevalence. We assessed worker seroprevalence in 2 slaughterhouses and 1 live-animal market in Abu Dhabi, United Arab Emirates, during 2014-2017 and administered an epidemiologic survey in 2016 and 2017. Across 3 sampling rounds during 2014-2017, we sampled 100-235 workers, and 6%-19% were seropositive for MERS-CoV at each sampling round. One (1.4%) of 70 seronegative workers tested at multiple rounds seroconverted. On multivariable analyses, working as a camel salesman, handling live camels or their waste, and having diabetes were associated with seropositivity among all workers, whereas handling live camels and either administering medications or cleaning equipment was associated with seropositivity among market workers. Characterization of high-risk exposures is critical for implementation of preventive measures.

Known human coronaviruses (hCoV) usually cause mild to moderate upper-respiratory tract illnesses, except SARS-CoV and MERS-CoV, which, in addition to mild illness can also be associated with severe respiratory diseases and high mortality rates. Well-characterized multiplexed serologic assays are needed to aid in rapid detection and surveillance of hCoVs. The present study describes development and evaluation of a multiplexed magnetic microsphere immunoassay (MMIA) to simultaneously detect immunoglobulin G (IgG) antibodies specific for recombinant nucleocapsid proteins (recN) from hCoVs 229E, NL63, OC43, HKU1, SARS-CoV, and MERS-CoV. We used paired human sera to screen for IgG with reactivity against six hCoVs to determine assay sensitivity, specificity and reproducibility. We found no signal interference between monoplex and multiplex assay formats (R(2) range = 0.87-0.97). Screening of paired human sera using MMIA, resulted in 92 of 106 (sensitivity: 86%) as positive and 68 of 80 (specificity: 84%) as negative. This study serves as a proof of concept that it is feasible to develop and use a multiplexed microsphere immunoassay as a next generation screening tool for use in large scale seroprevalence studies of hCoVs.

OBJECTIVE: To investigate a Middle East respiratory syndrome coronavirus (MERS-CoV) outbreak event involving multiple healthcare facilities in Riyadh, Saudi Arabia; to characterize transmission; and to explore infection control implications. DESIGN: Outbreak investigation. SETTING: Cases presented in 4 healthcare facilities in Riyadh, Saudi Arabia: a tertiary-care hospital, a specialty pulmonary hospital, an outpatient clinic, and an outpatient dialysis unit. METHODS: Contact tracing and testing were performed following reports of cases at 2 hospitals. Laboratory results were confirmed by real-time reverse transcription polymerase chain reaction (rRT-PCR) and/or genome sequencing. We assessed exposures and determined seropositivity among available healthcare personnel (HCP) cases and HCP contacts of cases. RESULTS: In total, 48 cases were identified, involving patients, HCP, and family members across 2 hospitals, an outpatient clinic, and a dialysis clinic. At each hospital, transmission was linked to a unique index case. Moreover, 4 cases were associated with superspreading events (any interaction where a case patient transmitted to >/=5 subsequent case patients). All 4 of these patients were severely ill, were initially not recognized as MERS-CoV cases, and subsequently died. Genomic sequences clustered separately, suggesting 2 distinct outbreaks. Overall, 4 (24%) of 17 HCP cases and 3 (3%) of 114 HCP contacts of cases were seropositive. CONCLUSIONS: We describe 2 distinct healthcare-associated outbreaks, each initiated by a unique index case and characterized by multiple superspreading events. Delays in recognition and in subsequent implementation of control measures contributed to secondary transmission. Prompt contact tracing, repeated testing, HCP furloughing, and implementation of recommended transmission-based precautions for suspected cases ultimately halted transmission.

OBJECTIVE: To describe recent syphilis trends among pregnant women and to evaluate the prevalence of reported high-risk behaviors in this population. METHODS: We analyzed U.S. national case report data for 2012-2016 to assess trends among pregnant women with all stages of syphilis. Risk behavior data collected through case interviews during routine local health department investigation of syphilis cases were used to evaluate the number of pregnant women with syphilis reporting these behaviors. RESULTS: During 2012-2016, the number of syphilis cases among pregnant women increased 61%, from 1,561 to 2,508, and this increase was observed across all races and ethnicities, all women aged 15-45 years, and all U.S. regions. Of 15 queried risk factors, including high-risk sexual behaviors and drug use, 49% of pregnant women with syphilis did not report any in the past year. The most commonly reported risk behaviors were a history of a sexually transmitted disease (43%) and more than one sex partner in the past year (30%). CONCLUSION: Syphilis cases among pregnant women increased from 2012 to 2016, and in half, no traditional behavioral risk factors were reported. Efforts to reduce syphilis among pregnant women should involve increasing health care provider awareness of the Centers for Disease Control and Prevention and the American College of Obstetricians and Gynecologists' recommendations, which include screening all pregnant women for syphilis at the first prenatal visit and rescreening high-risk women during the third trimester and at delivery. Health care providers should also consider local syphilis prevalence in addition to individual reported risk factors when deciding whether to repeat screening.

Middle East respiratory syndrome coronavirus (MERS-CoV) is associated with a wide range of clinical presentations, from asymptomatic or mildly ill to severe respiratory illness including death. We describe isolation of infectious MERS-CoV from the upper respiratory tract of a mildly ill 27-year-old female in Saudi Arabia 15 days after illness onset.

Background: An outbreak of Middle East respiratory syndrome coronavirus (MERS-CoV) in Jordan in 2015 involved a variant virus that acquired distinctive deletions in the accessory open reading frames. We conducted a molecular and seroepidemiologic investigation to describe the deletion variant's transmission patterns and epidemiology. Methods: We reviewed epidemiologic and medical chart data and analyzed viral genome sequences from respiratory specimens of MERS-CoV cases. In early 2016, sera and standardized interviews were obtained from MERS-CoV cases and their contacts. Sera were evaluated by nucleocapsid and spike protein enzyme immunoassays and microneutralization. Results: Among 16 cases, 11 (69%) had health care exposure and 5 (31%) were relatives of a known case; 13 (81%) were symptomatic, and 7 (44%) died. Genome sequencing of MERS-CoV from 13 cases revealed 3 transmissible deletions associated with clinical illness during the outbreak. Deletion variant sequences were epidemiologically clustered and linked to a common transmission chain. Interviews and sera were collected from 2 surviving cases, 23 household contacts, and 278 health care contacts; 1 (50%) case, 2 (9%) household contacts, and 3 (1%) health care contacts tested seropositive. Conclusions: The MERS-CoV deletion variants retained human-to-human transmissibility and caused clinical illness in infected persons despite accumulated mutations. Serology suggested limited transmission beyond that detected during the initial outbreak investigation.

Using National Ambulatory Medical Care Survey (NAMCS) data during 2006-2015, we estimated the proportions of young women tested for chlamydia who were symptomatic (urogenital symptoms) or asymptomatic in physician offices. Among women tested for chlamydia, the proportions of women with and without urogenital symptoms were 31.6% and 59.2%, respectively.

We compared the impact of a commercial chlorination product (brand name Air RahMat) in stored drinking water to traditional boiling practices in Indonesia. We conducted a baseline survey of all households with children 1000 MPN/100 ml (RR 1.86, 95% CI 1.09-3.19) in stored water than in households without detectable E. coli. Although results suggested that Air RahMat water treatment was associated with lower E. coli contamination and diarrhoeal rates among children <5 years than water treatment by boiling, Air RahMat use remained low.

The Centers for Disease Control and Prevention (CDC) algorithm for detecting presence of serum antibodies against Middle East Respiratory Syndrome coronavirus (MERS-CoV) in subjects with potential infections with the virus has included screening by indirect ELISA against recombinant nucleocapsid (N) protein and confirmation by immunofluorescent staining of infected monolayers and/or microneutralization titration. Other international groups include indirect ELISA assays using the spike (S) protein, as part of their serological determinations. In the current study, we describe development and validation of an indirect MERS-CoV S ELISA to be used as part of our serological determination for evidence of previous exposure to the virus.

BACKGROUND: During 8-20 April 2012, an outbreak of gastrointestinal illness occurred among guests and employees of a resort hotel in St. Thomas, US Virgin Islands. We describe outbreak characteristics, and estimate indirect (non-medical) costs to travellers. METHODS: Employees who met the case definition were interviewed and provided stool samples. Samples were tested for norovirus by real-time reverse-transcription polymerase chain reaction. Guests were asked to complete a survey aimed to identify and characterize cases, and to estimate quality adjusted vacation days (QAVD) lost. RESULTS: Overall, 66 persons (20 employees and 46 guests) met the probable case definition. The first reported illness onset occurred in a hotel employee on 8 April, while the first reported onset in a guest occurred on 13 April. An employee suffered a public diarrhoea incident on 13 April in the central kitchen, followed by illness onset in the next day among employees that assisted with the clean-up. On 15 April, after 10 guests reported ill, the hotel implemented an outbreak response protocol instructing ill employees to take a 3-day leave, and obtain medical clearance prior to resuming work. Ill guests were advised to self-isolate, and rapid cleaning of public areas and guest rooms where suspected contamination occurred was implemented. We estimated that 65 QAVDs were lost by 43 guests (1.5 days/guest). Using an approximate cost of $450 per vacation day, we estimated indirect illness cost at $675 per guest case. Seven (64%) of 11 cases' stool specimens were positive for norovirus genotype GII.4 Den Haag. CONCLUSIONS: A norovirus outbreak in a resort hotel resulted in substantial indirect costs and loss of vacation days to ill travellers. We recommend outbreak control measures including exclusion of ill employees, until ≥48-72 h after resolution of symptoms, self-isolation of ill guests and appropriate cleaning in hotel-associated norovirus outbreaks.

Evidence-based guidelines for implementation and measurement of antibiotic stewardship interventions in inpatient populations including long-term care were prepared by a multidisciplinary expert panel of the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. The panel included clinicians and investigators representing internal medicine, emergency medicine, microbiology, critical care, surgery, epidemiology, pharmacy, and adult and pediatric infectious diseases specialties. These recommendations address the best approaches for antibiotic stewardship programs to influence the optimal use of antibiotics.

Evidence-based guidelines for implementation and measurement of antibiotic stewardship interventions in inpatient populations including long-term care were prepared by a multidisciplinary expert panel of the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. The panel included clinicians and investigators representing internal medicine, emergency medicine, microbiology, critical care, surgery, epidemiology, pharmacy, and adult and pediatric infectious diseases specialties. These recommendations address the best approaches for antibiotic stewardship programs to influence the optimal use of antibiotics.

BACKGROUND: Although norovirus is the most common cause of gastroenteritis, there are few data on the community incidence of infection/disease or the patterns of acquired immunity or innate resistance to norovirus. METHODS: We followed a community-based birth cohort of 194 children in Ecuador with the aim to estimate (1) incidence of norovirus gastroenteritis from birth to three years (2) the protective effect of norovirus infection on subsequent infection/disease and (3) the association of infection/disease with secretor status. RESULTS: Over the 3-year period, we detected a mean of 2.26 (Range 0 - 12) diarrheal episodes per child. Norovirus was detected in 260 (18%) samples, but not more frequently in diarrhea samples (79/438; 18%) than diarrhea-free samples (181/1016; 18%, p=0.919). 66% of children had at least one norovirus infection during the first 3 years of life and 40% of children had two infections. Previous norovirus infections were not associated with subsequent risk of infection. All GII.4 infections were amongst secretor positive children (p<0.001), but higher rates of non-GII.4 infections were found in secretor-negative children (RR=0.56; p=0.029). CONCLUSIONS: GII.4 infections were uniquely detected in secretor positive children while non-GII.4 infections were more often found in secretor negatives.

Education, surveillance, and promotion of antimicrobial stewardship align with the goals of public health to prevent disease, promote health, and prolong life. Many US federal and state public health organizations are already engaged in antimicrobial stewardship activities. Healthcare providers are encouraged to work with public health officials on appropriate local antimicrobial stewardship strategies to attain the common goal of reducing antimicrobial resistance and preserving antimicrobials for future generations.

We describe four solid-organ transplant recipients with donor-derived West Nile virus (WNV) infection (encephalitis 3, asymptomatic 1) from a common donor residing in a region of increased WNV activity. All four transplant recipients had molecular evidence of WNV infection in their serum and/or cerebrospinal fluid (CSF) by reverse transcription polymerase chain reaction (RT-PCR) testing. Serum from the organ donor was positive for WNV IgM but negative for WNV RNA, whereas his lymph node and spleen tissues tested positive for WNV by RT-PCR. Combination therapy included intravenous immunoglobulin (4 cases), interferon (3 cases), fresh frozen plasma with WNV IgG (2 cases), and ribavirin (1 case). Two of the four transplant recipients survived.Review of the 20 published cases of organ-derived WNV infection found that this infection is associated with a high incidence of neuroinvasive disease (70%) and severe morbidity and mortality (30%). Median time to onset of symptomatic WNV infection was 13 days after transplantation (range 5-37 days). Initial unexplained fever unresponsive to antibiotic therapy followed by rapid onset of neurologic deficits was the most common clinical presentation. Confirmation of infection was made by testing serum and CSF for both WNV RNA by RT-PCR and WNV IgM by serological assays. Treatment usually included supportive care, reduction of immunosuppression, and frequent intravenous immunoglobulin. The often negative results for WNV by current RT-PCR and serological assays and the absence of clinical signs of acute infection in donors contribute to the sporadic occurrence of donor-derived WNV infection. Potential organ donors should be assessed for unexplained fever and neurological symptoms, particularly if they reside in areas of increased WNV activity.

OBJECTIVE: To investigate Acinetobacter baumannii infection, colonization, and transmission related to a long-term care facility (LTCF) providing subacute care (facility A). METHODS: We reviewed facility A and affiliated local hospital records for facility A residents with A. baumannii isolated during the period January 2009 through February 2010 and compared A. baumannii antimicrobial resistance patterns of residents with those of hospital patients. During March 2010, we implemented a colonization survey of facility A residents who received respiratory support or who could provide sputum samples and looked for A. baumannii colonization risks. Available clinical and survey isolates underwent pulsed-field gel electrophoresis (PFGE); PFGE strains were linked with overlapping stays to identify possible transmission. RESULTS: During the period January 2009 through February 2010, 33 facility A residents had A. baumannii isolates; all strains were multidrug resistant (MDR), which was a significantly higher prevalence of MDR strains than that found among isolates from hospital patients (81 [66%] of 122 hospital patient isolates were MDR; P < .001). The sputum survey found that 14 (20%) of 70 residents had A. baumannii colonization, which was associated with ventilator use (adjusted odds ratio, 4.24 [95% confidence interval, 1.06-16.93]); 12 (86%) of 14 isolates were MDR. Four facility A resident groups clustered with 3 PFGE strains and overlapping stays. One of these facility A residents also clustered with 3 patients at an affiliated hospital. CONCLUSIONS: We documented substantial MDR A. baumannii infections and colonization with probable intra- and interfacility spread associated with a single LTCF providing subacute care. Given the limited infection prevention and antimicrobial stewardship resources in such settings, regional collaborations among facilities across the spectrum of health care are needed to address this MDR threat.

BACKGROUND: In 2011, Sudan became the first low-income country in Africa to introduce a rotavirus vaccine. Prevaccine baseline data on rotavirus disease burden are crucial for monitoring the impact of this new vaccine program. METHODS: We conducted active, hospital-based surveillance for rotavirus disease at 8 regional public hospitals in Sudan using a standard protocol recommended by the World Health Organization for 2 full years immediately preceding vaccine introduction. Cases were children <5 years hospitalized with gastroenteritis, defined as acute onset of 3 or more loose stools or 2 or more episodes of vomiting in a 24-hour period. Stool specimens from cases were tested for rotavirus using a commercially available assay. RESULTS: From June 2009 to May 2011, rotavirus was detected in 3985 (36%) of 10,953 children hospitalized for gastroenteritis, with detection rates ranging from 25% to 48% at the 8 hospitals. Approximately 61% of the rotavirus hospitalizations occurred before 1 year of age and most (91%) occurred before 2 years of age. Rotavirus was detected year-round in Sudan with peaks during March to May and November to December. Applying rotavirus prevalence to national estimates of diarrhea events, we calculated 9800 deaths, 22,800 hospitalizations and 55,400 outpatient visits related to rotavirus per year among children <5 years of age in Sudan. CONCLUSIONS: The high burden of rotavirus disease in Sudan indicates that the recently implemented vaccination program should substantially improve child health in Sudan. This nationwide rotavirus surveillance system will be an important platform for assessing the benefits and value of rotavirus vaccine in a developing country setting.

Respiratory syncytial virus (RSV) is a high priority target for vaccine development. One concern in RSV vaccine development is that a non-live virus vaccine would predispose for enhanced disease similar to that seen with the formalin inactivated RSV (FI-RSV) vaccine. Since a mAb specific to RSV G protein can reduce pulmonary inflammation and eosinophilia seen after RSV infection of FI-RSV vaccinated mice, we hypothesized that RSV G peptides that induce antibodies with similar reactivity may limit enhanced disease after subunit or other non-live RSV vaccines. In support of this hypothesis, we show that FI-RSV vaccinated mice administered RSV G peptide vaccines had a significant reduction in enhanced disease after RSV challenge. These data support the importance of RSV G during infection to RSV disease pathogenesis and suggest that use of appropriately designed G peptide vaccines to reduce the risk of enhanced disease with non-live RSV vaccines merits further study.

Noroviruses are the leading cause of gastroenteritis in the United States, but timely measures of disease are lacking. BioSense, a national-level electronic surveillance system, assigns data on chief complaints (patient symptoms) collected during emergency department (ED) visits to 78 subsyndromes in near real-time. In a series of linear regression models, BioSense visits mapped by chief complaints of diarrhea and nausea/vomiting subsyndromes as a monthly proportion of all visits correlated strongly with reported norovirus outbreaks from 6 states during 2007-2010. Higher correlations were seen for diarrhea (R = 0.828-0.926) than for nausea/vomiting (R = 0.729-0.866) across multiple age groups. Diarrhea ED visit proportions exhibited winter seasonality attributable to norovirus; rotavirus contributed substantially for children <5 years of age. Diarrhea ED visit data estimated the onset, peak, and end of norovirus season within 4 weeks of observed dates and could be reliable, timely indicators of norovirus activity.

Although deaths are often reported in the context of norovirus outbreaks, clinical and epidemiologic characteristics of the decedents prior to death are not well established. Through a literature review of published reports of deaths associated with norovirus infection, we identified and summarized 158 norovirus-associated deaths in 12 countries from 1988 to 2011.

CONTEXT: Norovirus outbreaks are common among vulnerable, elderly populations in US nursing homes. OBJECTIVES: To assess whether all-cause hospitalization and mortality rates are increased during norovirus outbreak vs nonoutbreak periods in nursing homes, and to identify factors associated with increased risk. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study of Medicare-certified nursing homes in Oregon, Wisconsin, and Pennsylvania that reported at least 1 confirmed or suspected norovirus outbreak to the Centers for Disease Control and Prevention's National Outbreak Reporting System (NORS), January 2009 to December 2010. Deaths and hospitalizations occurring among residents of these nursing homes were identified through the Medicare Minimum Data Set (MDS). MAIN OUTCOME MEASURES: Rates of all-cause hospitalization and mortality during outbreak compared with nonoutbreak periods were estimated using a random-effects Poisson regression model controlling for background seasonality in both outcomes. RESULTS: The cohort consisted of 308 nursing homes that reported 407 norovirus outbreaks to NORS. Per MDS, 67 730 hospitalizations and 26 055 deaths occurred in these homes during the 2-year study. Hospitalization rates were 124.0 (95% CI, 119.4-129.1) vs 109.5 (95% CI, 108.6-110.3) hospitalizations per nursing home-year during outbreak vs nonoutbreak periods, yielding a seasonally adjusted rate ratio (RR) of 1.09 (95% CI, 1.05-1.14). Similarly, mortality rates were 53.7 (95% CI, 50.6-57.0) vs 41.9 (95% CI, 41.4-42.4) deaths per nursing home-year in outbreak vs nonoutbreak periods (seasonally adjusted RR, 1.11; 95% CI, 1.05-1.18). The increases in hospitalizations and mortality were concentrated in the first 2 weeks (week 0 and 1) and the initial week (week 0) of the outbreak, respectively. Homes with lower daily registered nurse (RN) hours per resident (<0.75) had increased mortality rates during norovirus outbreaks compared with baseline (RR, 1.26; 95% CI, 1.14-1.40), while no increased risk (RR, 1.03; 95% CI, 0.96-1.12) was observed in homes with higher daily RN hours per resident (P = .007 by likelihood ratio test); the increase in hospitalization rates did not show a similar pattern. CONCLUSION: Norovirus outbreaks were associated with significant concurrent increases in all-cause hospitalization and mortality in nursing homes.