Healthcare-associated infections (HAIs) pose a significant challenge in acute care hospitals, particularly in intensive care units, due to persistent environmental contamination despite existing disinfection protocols and manual cleaning methods. Current disinfection methods are labor-intensive and often ineffective against multidrug-resistant (MDR) pathogens, highlighting the need for new, automated, hands-free approaches.

This study evaluates the bactericidal efficacy of low concentrations of gaseous ozone (5 ppm) against clinically relevant and often MDR bacteria under various concentrations, contact times, temperatures, and environmental conditions.

We observed a 3 log10-fold reduction in Escherichia coli and Salmonella Typhimurium and a 1-2 log10-fold reduction in group A Streptococcus and methicillin-resistant Staphylococcus aureus upon ozone exposure. The bactericidal effect was dose-dependent, with no significant difference between single and repeated exposures. Environmental conditions such as temperature and humidity had minimal impact on low-dose ozone efficacy, with slightly improved bacterial killing at colder temperatures and higher humidity levels. Gaseous ozone also showed significant bactericidal activity against the broad range of Gram-positive and -negative MDR clinical isolates.

These findings highlight the potential of low-dose gaseous ozone as a versatile, effective, and hands-free disinfectant for healthcare and other settings. Further research is needed to establish long-term safety and efficacy guidelines for its use in occupied spaces and to explore potential synergy with other contemporary disinfection strategies.

Establish the influence of the terminal or nonterminal position of High Efficiency Particulate Air (HEPA) filters in the Heating, Ventilation, and Air Conditioning (HVAC) system on the presence of airborne fungi in controlled environment rooms.

Fungal infections are an important cause of morbidity and mortality in hospitalized patients.

This study was realized from 2010 to 2017, in rooms with terminal and nonterminal HEPA filters, in eight Spanish hospitals. In rooms with terminal HEPA filters, 2,053 and 2,049 samples were recollected, and in rooms with nonterminal HEPA filters, 430 and 428 samples were recollected in the air discharge outlet (Point 1) and in the center of the room (Point 2), respectively. Temperature, relative humidity, air changes per hour, and differential pressure were recollected.

Multivariable analysis showed higher odds ratio (OR) of airborne fungi presence when HEPA filters were in nonterminal position (OR: 6.78; 95% CI [3.77, 12.20]) in Point 1 and (OR: 4.43; 95% CI [2.65, 7.40]) in Point 2. Other parameters influenced airborne fungi presence, such as temperature (OR: 1.23; 95% CI [1.06, 1.41]) in Point 2 differential pressure (OR: 0.86; 95% CI [0.84, 0.90]) and (OR: 0.88; 95% CI [0.86, 0.91]) in Points 1 and 2, respectively.

HEPA filter in terminal position of the HVAC system reduces the presence of airborne fungi. To decrease the presence of airborne fungi, adequate maintenance of the environmental and design parameters is necessary in addition to the terminal position of the HEPA filter.

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.

The COVID-19 pandemic revealed opportunities to improve prevention practices in healthcare settings, mainly related to the spread of airborne microbes (also known as bioaerosols). This scoping review aimed to map methodologies used to assess the implementation of portable air cleaners in healthcare settings, identify gaps, and propose recommendations for future research. The protocol was registered in the Open Science Framework and reported following the checklist provided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis - an extension for Scoping Reviews (PRISMA-ScR) statement. The search strategy was performed in five databases and one grey literature source. At the last selection phase, 24 articles that fulfilled our inclusion criteria were summarized and disseminated. Of these, 17 studies were conducted between 2020 and 2022; one of them was a protocol of a multicentre randomized controlled trial. The outcomes measured among the studies include airborne microbe counts, airborne particle concentrations, and rate of infections/interventions. The leading healthcare settings assessed were dental clinics (28%), patient's wards (16%), operating rooms (16%), and intensive care units (12%). Most of the devices demonstrated a significant potential to mitigate the impact of bioaerosols. Although some indoor air quality parameters can influence the mechanics of aerosols, only a few studies controlled these parameters in their analyses. Future clinical research should assess the rate of infections through randomized controlled trials with long-term follow-up and large sample sizes to determine the clinical importance of the findings.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19), has spread globally. The major reservoir for SARS-CoV-2 transmission remains controversial, with the airborne route remaining a possible transmission vehicle for carrying the virus within indoor environments. This study aimed to detect contamination of SARS-CoV-2 in high-efficiency particulate air (HEPA) filters within hospital isolation rooms of confirmed COVID-19 patients, exploring the role of nano-treatment of these filters with silver and titanium dioxide nanoparticles (Ag/TiO₂ NPs).

We investigated the effectiveness of Ag-NPs/TiO₂-treated HEPA filters in the air of rooms occupied by patients with confirmed COVID-19 in a university teaching hospital in the Eastern province of Saudi Arabia during the first wave of the pandemic. Ag/TiO₂ NPs were designed and coated on HEPA filters to examine the filtration efficiency and antiviral ability in the presence of aerosolized virus particles. A total of 20 viral swab samples were collected from five patients' rooms before and after treatment with nanoparticle-prepared solutions into the sterile virus-transporting media. Samples were evaluated for SARS-CoV-2 with a reverse transcription-polymerase chain reaction.

Two samples taken from the HEPA filter air exhaust outlets prior to nano-treatment tested positive for SARS-CoV-2 RNA in the intensive care unit, which has stringent aerosolization control procedures, suggesting that small virus-laden droplets may be displaced by airflow. All air samples collected from the HEPA filters from the rooms of patients with confirmed COVID-19 following nano-treatment were negative.

We recommend further experimental exploration using a larger number of HEPA filters in areas with aerosol-generating procedures, along with viability studies on the HEPA filters to facilitate decision-making in high-risk facilities regarding the replacement, storage, and disposal of HEPA filters in wards occupied by cases diagnosed with a highly transmissible disease.

Clostridioides difficile (C. difficile) is a gram-positive, anaerobic spore-forming bacterium and a major cause of antibiotic-associated diarrhea. Humans are naturally resistant to C. difficile infection (CDI) owing to the protection provided by healthy gut microbiota. When the gut microbiota is disturbed, C. difficile can colonize, produce toxins, and manifest clinical symptoms, ranging from asymptomatic diarrhea and colitis to death. Despite the steady-if not rising-prevalence of CDI, it will certainly become more problematic in a world of antibiotic overuse and the post-antibiotic era. C. difficile is naturally resistant to most of the currently used antibiotics as it uses multiple resistance mechanisms. Therefore, current CDI treatment regimens are extremely limited to only a few antibiotics, which include vancomycin, fidaxomicin, and metronidazole. Therefore, one of the main challenges experienced by the scientific community is the development of alternative approaches to control and treat CDI. In this Frontier article, we collectively summarize recent advances in alternative treatment approaches for CDI. Over the past few years, several studies have reported on natural product-derived compounds, drug repurposing, high-throughput library screening, phage therapy, and fecal microbiota transplantation. We also include an update on vaccine development, pre- and pro-biotics for CDI, and toxin antidote approaches. These measures tackle CDI at every stage of disease pathology via multiple mechanisms. We also discuss the gaps and concerns in these developments. The next epidemic of CDI is not a matter of if but a matter of when. Therefore, being well-equipped with a collection of alternative therapeutics is necessary and should be prioritized.

The outbreak of SARS-CoV-2 has made us all think critically about hospital indoor air quality and the approaches to remove, dilute, and disinfect pathogenic organisms from the hospital environment. While specific aspects of the coronavirus infectivity, spread, and routes of transmission are still under rigorous investigation, it seems that a recollection of knowledge from the literature can provide useful lessons to cope with this new situation. As a result, a systematic literature review was conducted on the safety of air filtration and air recirculation in healthcare premises. This review targeted a wide range of evidence from codes and regulations, to peer-reviewed publications, and best practice standards. The literature search resulted in 394 publications, of which 109 documents were included in the final review. Overall, even though solid evidence to support current practice is very scarce, proper filtration remains one important approach to maintain the cleanliness of indoor air in hospitals. Given the rather large physical footprint of the filtration system, a range of short-term and long-term solutions from the literature are collected. Nonetheless, there is a need for a rigorous and feasible line of research in the area of air filtration and recirculation in healthcare facilities. Such efforts can enhance the performance of healthcare facilities under normal conditions or during a pandemic. Past innovations can be adopted for the new outbreak at low-to-minimal cost.

Central line-associated bloodstream infection (CLABSI) remains prevalent in hospitals in the United States.

To evaluate the impact of a multimodal intervention in hospitals with elevated rates of health care-associated infection.

Pre-post observational evaluation of a prospective, national, clustered, nonrandomized initiative of 3 cohorts of hospitals.

Acute care, long-term acute care, and critical access hospitals, including intensive care units and medical/surgical wards.

Target hospitals had a cumulative attributable difference above the first tertile of performance for Clostridioides difficile infection and another health care-associated infection (such as CLABSI). Some hospitals that did not meet these criteria also participated.

A multimodal intervention consisting of recommendations and tools for prioritizing and implementing evidence-based infection prevention strategies, on-demand educational videos, webinars led by content experts, and access to content experts.

Rates of CLABSI and device utilization ratio pre- and postintervention.

Between November 2016 and May 2018, 387 hospitals in 23 states and the District of Columbia participated. Monthly preimplementation CLABSI rates ranged from 0 to 71.4 CLABSIs per 1000 catheter-days. Over the study period, the unadjusted CLABSI rate was low and decreased from 0.88 to 0.80 CLABSI per 1000 catheter-days. Between the pre- and postintervention periods, device utilization decreased from 24.05 to 22.07 central line-days per 100 patient-days. However, a decreasing trend in device utilization was also observed during the preintervention period.

The intervention period was brief. Participation in and adherence to recommended interventions were not fully assessed. Rates of CLABSI were low. Patient characteristics could not be assessed.

In hospitals with a disproportionate burden of health care-associated infection, a multimodal intervention did not reduce rates of CLABSI.

Centers for Disease Control and Prevention.

The Centers for Disease Control and Prevention (CDC) funded a 3-year national collaborative focused on facilitating relationships between health care-associated infection (HAI) prevention stakeholders within states and improving HAI prevention activities within hospitals. This program-STRIVE (States Targeting Reduction in Infections via Engagement)-targeted hospitals with elevated rates of common HAIs.

To use qualitative methods to better understand STRIVE's effect on state partner relationships and HAI prevention efforts by hospitals.

Qualitative case study, by U.S. state.

7 of 22 eligible STRIVE state partnerships.

Representatives from state hospital associations, state health departments, and other participating organizations (for example, Quality Innovation Networks-Quality Improvement Organizations), referred to as "state partners."

Phone interviews (n = 17) with each organization were conducted, recorded, and transcribed.

State partners reported that relationships with each other and with participating hospitals improved through STRIVE participation. The partners saw improvements in hospital-level HAI prevention activities, such as improved auditing and feedback practices and inclusion of environmental services in prevention efforts; however, some noted those improvements may not be reflected in HAI rates. Many partners outlined plans to sustain their partner relationships by working on future state-level initiatives, such as opioid abuse prevention and antimicrobial stewardship.

Only 7 participating states were included; direct feedback from participating hospitals was not available.

Although there were no substantial changes in aggregate HAI rates, STRIVE achieved its goal of improving state partner relationships and coordination. This improved collaboration may lead to a more streamlined response to future HAI outbreaks and public health emergencies.

Centers for Disease Control and Prevention.

Many hospitals struggle to prevent catheter-associated urinary tract infection (CAUTI).

To evaluate the effect of a multimodal initiative on CAUTI in hospitals with high burden of health care-associated infection (HAI).

Prospective, national, nonrandomized, clustered, externally facilitated, pre-post observational quality improvement initiative, for 3 cohorts active between November 2016 and May 2018.

Acute care, long-term acute care, and critical access hospitals, including intensive care and non-intensive care wards.

Target hospitals had a high burden of Clostridioides difficile infection plus central line-associated bloodstream infection, CAUTI, or hospital-onset methicillin-resistant Staphylococcus aureus bloodstream infection, defined as cumulative attributable differences above the first tertile in the Targeted Assessment for Prevention (TAP) strategy. Some additional nonrecruited hospitals also joined.

Multimodal intervention, including Practice Change Assessment tool to identify infection prevention and control (IPC) and HAI prevention gaps; Web-based, on-demand modules involving onboarding, foundational IPC practices, HAI-specific 2-tiered approach to prioritize and implement interventions, and TAP resources; monthly webinars; state partner-led in-person meetings; and feedback. State partners made site visits to at least 50% of their enrolled hospitals, to support self-assessments and coach.

Rates of CAUTI and urinary catheter device utilization ratio.

Of 387 participating hospitals from 23 states and the District of Columbia, 361 provided CAUTI data. Over the study period, the unadjusted CAUTI rate was low and relatively stable, decreasing slightly from 1.12 to 1.04 CAUTIs per 1000 catheter-days. Catheter utilization decreased from 21.46 to 19.83 catheter-days per 100 patient-days from the pre- to the postintervention period.

The intervention period was brief, with no assessment of fidelity. Baseline CAUTI rates were low. Patient characteristics were not assessed.

This multimodal intervention yielded no substantial improvements in CAUTI or urinary catheter utilization.

Centers for Disease Control and Prevention.

Methicillin-resistant Staphylococcus aureus (MRSA) remains one of the most common causes of health care-associated infection (HAI).

To evaluate the effect of education and a tiered, evidence-based infection prevention strategy on rates of hospital-onset MRSA bloodstream infection (BSI).

Prospective, national, nonrandomized, interventional, 12-month, multiple cohort, pre-post observational quality improvement project.

Acute care, long-term acute care, and critical access hospitals with a disproportionate burden of HAI.

All patients admitted to participating facilities during the project period.

A multimodal infection prevention intervention consisting of recommendations and tools for prioritizing and implementing evidence-based infection prevention strategies, on-demand educational videos, Internet-based live educational presentations, and access to content experts.

Rates of hospital-onset MRSA BSI, overall and stratified by hospital type, during 12-month baseline and postintervention periods. Variation in outcomes across hospital types was examined.

Between November 2016 and May 2018, 387 hospitals in 23 states and the District of Columbia participated, 353 (91%) submitted MRSA data, and 172 (49%) indicated that MRSA prevention was a priority. Unadjusted overall rates of hospital-onset MRSA BSI were 0.075 (95% CI, 0.065 to 0.085) and 0.071 (CI, 0.063 to 0.080) per 1000 patient-days in the baseline and postintervention periods, respectively.

The intervention period was short. Participation and adherence to recommended interventions were not fully assessed. Baseline rates of hospital-onset MRSA BSI were relatively low. Prevention of MRSA was a priority in a minority of participating hospitals. Patient characteristics and other MRSA risk factors were not assessed.

In hospitals with a disproportionate burden of HAIs, access to tools to assist with implementation of evidence-based prevention strategies and education resources alone may not be sufficient to prevent MRSA BSI.

Centers for Disease Control and Prevention.

Clostridioides difficile infection (CDI) is on the rise.

To evaluate the effect of a tiered, evidence-based intervention to prevent CDI.

Pre-post observational evaluation of a prospective, 12-month, national, nonrandomized, clustered quality improvement project to reduce hospital health care-associated infection.

Acute care, long-term acute care, and critical access hospitals working with state partner organizations (state hospital associations and state health departments) to improve health care-associated infection prevention practices.

Targeted hospitals had a high burden of CDI and another health care-associated infection. Other hospitals that did not meet these criteria volunteered to participate.

Multimodal intervention that consisted of 1) on-demand educational modules and webinars, 2) in-person meetings facilitated by state-level partners, 3) feedback and recommendations for implementation of evidence-based recommendations (including a CDI-specific guide on which interventions to implement), and 4) guided facilitation through infection prevention resources and site visits.

Pre- and postintervention CDI rates.

Between November 2016 and May 2018, 387 hospitals (366 of which reported CDI data) in 23 states and the District of Columbia participated in the intervention. There was a statistically significant decrease in CDI incidence over the study period, from 7.0 cases per 10 000 patient-days in the preintervention period to 5.7 cases per 10 000 patient-days in the postintervention period. However, this decrease appeared to be part of a temporal trend rather than due to the study intervention.

Commitment to and adherence with recommended infection prevention practices before and after the intervention were not assessed. The intervention period was relatively brief, and patient-level data were not available.

Although a statistically significant decline in hospital-onset CDI was observed, this trend appears to be unrelated to the study intervention.

Centers for Disease Control and Prevention.