Background: Resilient healthcare systems prevent, absorb, and learn from stressors. Identifying resilient performance in healthcare systems can be challenging due to complex underlying processes and associated outcomes. This study aimed to identify resilient performance in US outpatient hemodialysis (HD) facilities during the COVID-19 pandemic by characterizing associated operational factors and classifying longitudinal patterns in bloodstream infections (BSI) rates using machine learning. Methods: This study used longitudinal BSI data reported to National Healthcare Safety Network (NHSN) by outpatient HD facilities during pre-pandemic (April 1, 2018–April 30, 2019) and pandemic (April 1, 2021–April 30, 2023) periods. For each period, facilities were classified into distinct patterns based on facility-level BSI rates (cases per 100 patient months) using k-means clustering for longitudinal data (KmL), an unsupervised machine-learning method. CMS Dialysis Facility data provided key facility characteristics and NHSN Annual Dialysis Facility Surveys provided use of Core Interventions for Dialysis BSI Prevention. Facility resilience was operationalized as classification in a lower BSI rate cluster during the pandemic period. Associations between KmL classification during the pandemic and facility operational factors were assessed using multivariable logistic regression. Result: Of 7084 outpatient HD facilities, 4907 (69%) reported BSIs to NHSN during both periods and linked to CMS data. KmL grouped facilities into two clusters for each period. During the pandemic, a lower-rate cluster (n=4132, 84%) and a higher rate cluster (n=775, 16%) had mean BSI rates of 0.19 and 0.76 per 100 patient-months, respectively. Both clusters reported strong implementation of Core Interventions; however, the higher-rate cluster had increased odds of implementing ≤64% of interventions. In the multivariable model, facilities in the higher-rate pandemic cluster were associated with being in the higher-rate pre-pandemic cluster, structural factors (non-profit ownership, non-chain facility status, having <20 dialysis stations), processes (increased central vascular catheter use, lower use of antiseptic-impregnated catheter end caps, rarely administering antibiotics before obtaining blood cultures for suspected BSIs), and geography (Northeast or Midwest US location, rurality). Conclusion: Using machine learning, two distinct BSI rate trajectories emerged before and during the COVID-19 pandemic, with key operational differences between facility groups. Facilities demonstrating lower and stable BSI trajectories during pandemic could be interpreted as exhibiting more resilient performance under system stressors. This approach can inform resilient performance across other patient safety processes, healthcare settings, and system stressors. Understanding structures and processes associated with patient safety outcomes during disruption can support public health prioritization and targeted interventions to strengthen healthcare system resilience.

Background: As coronavirus disease 2019 (COVID-19) has evolved, patients increasingly present with milder disease, raising questions about optimal management of those hospitalized for other conditions, but found to have COVID-19 with high risk of progression. While these patients may traditionally be managed with a 3-day course of remdesivir (RDV) and nirmatrelvir/ritonavir (N/R) in the outpatient setting, these therapies have not been explicitly studied in a similar population, but in the inpatient setting. Objective: To evaluate outcomes with 3-day RDV versus 5-day N/R in high-risk hospitalized patients with mild COVID-19. Methods: This single-center, retrospective, propensity score-matched cohort study included hospitalized adult patients who were found to have mild COVID-19 between January 2023 and December 2023. Patients were grouped by treatment received, including 3-day RDV or 5-day N/R. Baseline characteristics and risk factors for disease progression were collected. Endpoints included incidence of disease progression, need for oxygen and respiratory support, length of stay, 30-day readmission, and mortality. Results: One-hundred and fifty patients were included in the analysis, with 75 in each group. Baseline characteristics between groups were similar. There was no significant difference in the rate of disease progression between the RDV and N/R group (19% vs 11%, respectively; P = 0.166). There was no difference in additional endpoints including hospital length of stay, 30-day readmission, or mortality. Conclusion: There was no significant difference in rates of disease progression or other outcomes among high-risk hospitalized adults with mild COVID-19 treated with RDV or N/R. Larger studies are needed to confirm these findings.

OBJECTIVE:To assess differences in SARS-CoV-2 infection rates between patients receiving hemodialysis in outpatient centers (in-center) and those receiving dialysis in their homes (hemodialysis and peritoneal dialysis) from December 29, 2020, through May 9, 2023. DESIGN:Retrospective cohort study. SETTING:Outpatient dialysis facilities in the United States reporting to the Centers for Disease Control and Prevention's National Healthcare Safety Network. PATIENTS:Maintenance dialysis patients that received hemodialysis treatment at or were affiliated with outpatient dialysis facilities. METHODS:SARS-CoV-2 infection rates were assessed by dialysis setting (in-center and home). Weeks were categorized as surge (rate of infection > median) and non-surge (rate of infection ≤ median) and by variant predominance. A negative binomial regression model with generalized estimating equations was constructed to examine differences in rates of infection among patients. RESULTS:A total of 7,974 dialysis facilities reported 171,338 SARS-CoV-2 infections among patients. In-center hemodialysis patients had higher average rates of SARS-CoV-2 infection at 2.85 infections per 1000 patient-weeks than home patients at 1.69 infections per 1000 patient-weeks. During surge weeks, the differences in rates of infection between in-center and home patients were more pronounced than during non-surge weeks for all variant predominance categories: Delta (relative rate ratio (RRR) = 1.20, CI: 1.09-1.32), B.1 and Other (RRR = 1.11, CI: 1.02-1.22), and Omicron (RRR = 1.07, CI: 1.01-1.12). CONCLUSION:Rates of SARS-CoV-2 infection among patients receiving outpatient hemodialysis were persistently higher than rates among patients receiving dialysis treatments at home; these differences were more pronounced during surge weeks.

Nursing home residents and health care personnel (HCP) are at increased risk for exposure to influenza; in addition, residents of nursing homes who acquire influenza are at increased risk for severe disease. The Advisory Committee on Immunization Practices recommends routine annual seasonal influenza vaccination for persons without contraindications, including HCP and those at increased risk for severe influenza. Nursing homes report influenza vaccination among residents and HCP to CDC's National Healthcare Safety Network. This report describes influenza vaccination coverage among nursing home residents and HCP working in nursing homes during the 2024-25 influenza season (October 1, 2024-March 31, 2025). At the end of the 2024-25 influenza season, influenza vaccination coverage was 61.3% among nursing home residents and 42.1% among HCP who work in nursing homes; coverage among HCP varied by employment type. This study is the first comprehensive, national assessment of influenza vaccination coverage among nursing home residents and HCP who work in nursing homes in the United States. Monitoring of influenza vaccination coverage in this population at high risk for influenza exposure and severe influenza disease, along with implementation of a combination of influenza vaccination, administration of influenza antiviral medications, and other recommended practices to control the spread and severity of influenza in nursing home settings, can help protect nursing home residents and HCP against severe influenza-associated outcomes.

Caribbean countries are among the most heavily burdened by both human immunodeficiency virus (HIV) and cancer, with prevalent stigmatization of both illnesses. This novel pilot study responds to the need to examine and understand both cancer- and HIV-related stigma among cancer survivors living with HIV (CSLWH). Data were collected via quantitative surveys and administered in person in Trinidad and Tobago. The survey used in this pilot study included an HIV stigma scale and a cancer stigma scale. Descriptive analyses were conducted using IBM SPSS Statistics 29.0.0. For most stigma items, HIV stigma is higher than cancer stigma, especially for personal and relational self-stigma: 95

BACKGROUND:Globally, Caribbean countries are among the most heavily burdened by both human immunodeficiency virus and cancer. Due to their immunocompromised status, people living with human immunodeficiency virus (PLWH) are more susceptible to human papillomavirus (HPV)-related cancers. METHODS:We conducted a preliminary study evaluating HPV vaccination rates targeting PLWH in Trinidad and Tobago using data from local clinics. This study provided descriptive analysis results, including demographic characteristics of enrolled PLWH and HPV vaccination rates. RESULTS:A total of 5,615 PLWH (age ranged from 18 to 51 years, with 51.4% women and 48.6% men) were enrolled in this evaluation. Of these, 1,178 patients (21.0%) received HPV vaccines: 22.8% were vaccinated with one dose, 25.6% were vaccinated with two doses, and 51.6% were vaccinated with three doses. The highest uptake of 22.3% was in 2021, followed by 20.1% in 2022, but in 2023, it dropped to 15.5%. Between 2018 and 2020, the uptakes were 13.6% for 2020, 12.7% for 2019, and 5.7% for 2018. CONCLUSIONS:Overall, the HPV vaccination rates among PLWH in Trinidad and Tobago are low; only one in five was vaccinated. IMPACT:Results suggest that by implementing comprehensive and targeted programs, clinics have the potential to successfully implement HPV vaccinations toward significantly reducing the incidence and mortality of HPV-related cancers and saving lives. There is a trend with the highest vaccination uptake during the peak years of COVID-19 vaccinations, with HPV vaccination rates almost doubling between 2019 and 2021. Hence, our data suggest that the COVID-19 vaccination program may have boosted HPV vaccination.

Abstract Background As the Coronavirus disease 2019 (COVID-19) has evolved, patients often present with mild-to-moderate disease as opposed to severe disease that was seen earlier in the pandemic. Two previously published studies (PINETREE and EPIC-HR) evaluated treatment options in the outpatient setting for patients with mild-to-moderate disease. These studies may provide insight into how patients with similar disease presentation may be treated in the inpatient setting. The purpose of this study was to evaluate the use of nirmatrelvir (N/R) and short-course remdesivir in high-risk patients hospitalized with mild-to-moderate COVID-19. Clinical Outcomes in the Propensity-Matched Cohort Methods This was a single-center, retrospective cohort study including adult patients hospitalized for mild-to-moderate COVID-19 between January 2021 and December 2023. Patients were grouped by treatment received (N/R or short-course [3-day] remdesivir). They were excluded if they received additional COVID-19 therapies, did not receive the appropriate regimen or were treated prior to hospitalization. Patients were compared by treatment received after propensity score-matching based on baseline characteristics. The primary endpoint assessed was the need for oxygen support. Exploratory endpoints included need for mechanical ventilation, length of stay, 30-day readmission, and mortality. Results Eight-hundred and fifty-six patients were initially screened. After exclusions and propensity score-matching, a total of 75 matched pairs (N=150) were included in the analysis. Patients had an average of three comorbidities or high risk features for COVID-19 progression, most commonly age greater than 60 years, BMI over 25 kg/m2, hypertension, and diabetes. There was no difference in the primary outcome of need for oxygen support in the short-course remdesivir group compared to the N/R group (14 [19%] vs 7 [9%], respectively; p=0.100). There was also no difference in length of stay between the two groups (5 [3, 7] vs 4 [2, 7] days, respectively; p=0.068). All additional endpoints were similar between short-course remdesivir and N/R. Conclusion Patients at high-risk of progression with mild-to-moderate COVID-19 that received N/R or short-course remdesivir had similar rates of disease progression, length of stay, readmissions, and mortality. Disclosures Jonathan Edwards, PharmD, BCPS, BCGP, BCIDP, Gilead Sciences, Inc.: Advisor/Consultant|Gilead Sciences, Inc.: Honoraria

Background: Client satisfaction with HIV service delivery reflects the ability of healthcare providers to effectively deliver care and treatment that meets the requirements and expectations of clients, and is associated with improved health outcomes, including increased retention in care and HIV viral suppression. The aim of the study was to conduct a client satisfaction study among PLHIV attending a large HIV clinic in Trinidad to identify the gaps in service delivery and factors associated with reduced HIV viral suppression. Methods: This cross-sectional study was conducted over the period April 2023-March 2024 among 362 clients attending the HIV clinic. A structured, pre-tested questionnaire collected demographic data and factors that affected client clinic experiences, including wait time, communication with staff, confidentiality, physical amenities and HIV viral suppression. Multivariable logistic regression was used to assess the likelihood of reporting satisfaction based on key independent variables. Results: Among participants, 219 (60.5%) were females, 202 (55.8%) were aged 30-49 years and 337 (93.1%) were virally suppressed. Participants reported satisfaction with overall care (95.3%), confidentiality (95.9%) and interactions with doctors (96.1%), nurses (98.6%) and other staff. Dissatisfaction was reported with facility-related, elements including the outdoor/tented waiting area (46.1%), the toilet/washrooms (37.0%) and the clinic wait time (31.8%). Participants were less likely to be satisfied with the amount of medication received if they had unsuppressed viral loads (p = 0.035), were aged 20-29 years old (p = 0.048) or had a tertiary education (p = 0.008). Conclusions: The study showed that 93.1% of the study participants were virally suppressed, and there was a general level of satisfaction with the overall care at the clinic, confidentiality and healthcare workers' service delivery; however, gaps involving the physical facilities, wait times and medication services should be prioritized.

Unlabelled:The National Healthcare Safety Network (NHSN) of the Centers for Disease Control and Prevention (CDC) needed a modernized approach to manage resources containing standardized terminology that specify microorganism data submitted electronically for legacy reporting. Health care-associated infections (HAIs) reported to NHSN require the submission of data regarding specific microorganisms attributed to the patient's condition. Data on microorganisms submitted to the NHSN electronically must use the SNOMED CT terminology standard. Terminology artifacts that guide submission of microorganism data have been maintained in spreadsheets that have become increasingly challenging to manage. This case report details the initial use case for the implementation of off-the-shelf software within the NHSN to modernize the maintenance of terminology assets. Resources that guide reporting microorganisms for HAIs were used as a prototype to demonstrate how a software application can be practically implemented to streamline the maintenance of complex terminology assets. Mission-critical artifacts have been reconciled and consolidated into a single source of truth knowledgebase using an off-the-shelf software solution. This report shares progress and lessons learned regarding the modernization of NHSN's Pathogen Codes resource and its derivative artifacts. A model is now available that can be replicated across other NHSN legacy artifacts. Our experience can be applied to other public health use cases and information systems facing similar challenges with attachments to legacy terminology resources and systems.

Objective: The purpose of the study is to analyze bloodstream infection (BSI) data reported by outpatient hemodialysis facilities to understand temporal trends, the potential impact of infection prevention practices and the COVID-19 pandemic on BSI rates.Methods: Outpatient hemodialysis facilities report BSI data to the National Healthcare Safety Network. We used interrupted time series with mixed effects negative binomial modeling to estimate the annual change of BSI rates from 2012 to 2021, using March 2020 as the COVID-19 inflection point. The model controlled for seasonal factors, vascular access types, and facility characteristics.Results: The number of facilities used for analysis increased from 5,581 in 2012 to 7,313 in 2021. Most facilities were freestanding (range: 90%-93%) and belonged to for-profit organizations (range: 85%-88%). The annual adjusted BSI rates decreased by an average of 8.90% (95% CI: -9.10 %, -8.71%) January 2012-February 2020. The annual decrease in BSI rate was not significant during March 2020-December 2021 (P = 0.15). There was a level drop of 32.03% (95%CI: -33.84%, -30.17%) in BSI rates in the period of March 2020-December 2021 compared with the period of January 2012-February 2020.Conclusions: BSI rates decreased steadily from January 2012 to February 2020 likely due to the identification and adoption of evidence-based prevention practices. BSI rates plateaued at lower levels during March 2020-December 2021. This suggests that infection prevention measures implemented by facilities prior to the emergence of COVID-19 contributed to substantial decreases in BSI rates and may have helped to stabilize BSI rates after March 2020.

OBJECTIVE:This study aims to assess the risk of a malaria outbreak in Trinidad and Tobago (T&T) based on trends in imported cases from two malaria-endemic high-population-mobility countries, Guyana and Venezuela, for the period 2009-2019. METHODS:A census of all positive malaria cases in T&T for the period 2009-2019 was obtained from the Insect Vector Control Division of the Ministry of Health. This included sociodemographic data, malaria type, origin, and whether it was acquired locally or was imported. Over the study period, data on the number of arrivals from Guyana and Venezuela to all ports of entry were obtained from the Immigration Division. Descriptive analyses and linear regression analyses were used to investigate the relationship between positive malaria cases and Guyanese and Venezuelan arrivals. RESULTS:There were 211 positive malaria cases in the study; ages ranged from 3 to 81 years, with a mean age of 35 years (SD = 14.3), and 74% were males. Among malaria cases, the common parasites were Plasmodium vivax (68.2%) and Plasmodium falciparum (22.3%). The majority (91.9%) were imported, 6.2% were acquired locally, and 1.9% were of unknown origin. Of the 194 imported cases, the countries of origin were Guyana (39.7%), Venezuela (38.7%), and Sub-Saharan Africa (15.5%). The correlation between log-transformed Venezuelan arrivals and malaria cases was moderate (r = 0.642, R2 = 0.412) and reached statistical significance (p = 0.033), indicating that Venezuelan arrivals significantly predict malaria incidence. CONCLUSION:Population movement from high malaria risk areas may increase the likelihood of transmission in T&T, and the influx of people from Venezuela significantly predicts malaria incidence. Malaria literacy, health education, surveillance, prompt diagnosis, treatment, and vector control are some of the interventions urgently needed to prevent a malaria resurgence.

In the original publication [...].

The simultaneous circulation of seasonal influenza virus and SARS-CoV-2 variants will likely pose unique challenges to public health during the future influenza seasons. Persons who are undergoing treatment in healthcare facilities may be particularly at risk. It is important for healthcare personnel to protect themselves and patients by receiving vaccines. The purpose of this study is to assess coverage of the seasonal influenza vaccine and COVID-19 monovalent booster among healthcare personnel working at acute care hospitals in the United States during the 2021-22 influenza season and to examine the demographic and facility characteristics associated with coverage. A total of 3260 acute care hospitals with over 7 million healthcare personnel reported vaccination data to National Healthcare Safety Network (NHSN) during the 2021-22 influenza season. Two separate negative binomial mixed models were developed to explore the factors associated with seasonal influenza coverage and COVID-19 monovalent booster coverage. At the end of the 2021-2022 influenza season, the overall pooled mean seasonal influenza coverage was 80.3%, and the pooled mean COVID-19 booster coverage was 39.5%. Several demographic and facility-level factors, such as employee type, facility ownership, and geographic region, were significantly associated with vaccination against influenza and COVID-19 among healthcare personnel working in acute care hospitals. Our findings highlight the need to increase the uptake of vaccination among healthcare personnel, particularly non-employees, those working in for-profit and nonmedical school-affiliated facilities, and those residing in the South.

METHODS:Outpatient hemodialysis facilities report BSI events to NHSN. Pooled mean rates with 95% CI were calculated overall and for each type of vascular access (arteriovenous (AV) fistula, AV graft, or a central venous catheter (CVC)). Standardized infection ratios were calculated as observed BSI events divided by the predicted number of events based on national aggregate data. Median facility-level standardized infection ratios and 95% confidence intervals (CIs) were stratified by state and US territory.RESULTS:During 2020, 7,183 outpatient hemodialysis facilities reported data for 5,235,234 patient months with 15,181 BSI events. Pooled mean rates per 100 person-months were 0.29 (95% CI, 0.29-0.30) overall, 0.80 (95% CI, 0.78-0.82) for CVC, 0.12 (95% CI, 0.12-0.12) for AV fistula, 0.21 (95% CI, 0.20-0.22) for AV graft, and 0.28 (95% CI, 0.19-0.40) for other access types. The national standardized infection ratio was 0.40 (95% CI, 0.39-0.41). South Dakota had a standardized infection ratio significantly higher than one (1.34; 95% CI, 1.11 - 1.62). Fifty-one of 54 states and territories had BSI standardized infection ratio significantly lower than one.CONCLUSIONS:In 2020, the median standardized infection ratio for BSI in US outpatient hemodialysis facilities was lower than predicted overall and in almost all states and territories. An elevated standardized infection ratio was identified in South Dakota.

Background: Oritavancin and dalbavancin are long-acting lipoglycopeptide antibiotics approved for the treatment of skin and skin structure infections. Recently, they have been used for outpatient antimicrobial therapy for complicated infections. No head-to-head studies exist for this purpose. Objective: To compare outcomes of patients treated with multiple doses of oritavancin or dalbavancin for complicated infections. Patients and Methods: This was a single-centre, retrospective cohort study evaluating adult patients who received two or more doses of lipoglycopeptides for complicated infections from February 2019 through December 2022. Patients receiving oritavancin were compared to dalbavancin after propensity scorematching. The primary endpoint was clinical success at 90 days. Other endpoints included: 30-day readmission, 30-day mortality, adverse drug reactions (ADRs), and changes in white blood cell count and inflammatory markers after the first dose. Results: After exclusions and propensity score-matching, 131 matched pairs (N = 262) were included in the analysis. Most patients were receiving lipoglycopeptide therapy for osteomyelitis. There was no significant difference in clinical success at 90 days in patients who received oritavancin compared to those who received dalbavancin (99 [76%] vs. 103 [79%], respectively; P = 0.556). There was no significant difference in secondary endpoints, however, there was a trend towards higher incidence of ADRs oritavancin compared to dalbavancin (9 [7%] vs. 2 [2%], respectively; P = 0.060) which led to more treatment discontinuation. Conclusion: There was no significant difference in efficacy between multi-dose oritavancin and dalbavancin for the treatment of complicated infections. Both agents were generally well tolerated; however, dalbavancin may be better tolerated when long-term treatment is warranted. (c) 2024 Elsevier Ltd and International Society of Antimicrobial Chemotherapy. All rights reserved.