scholarly journals Evaluation of Novel “No-Touch” Technologies for Decontamination of Toys in Pediatric Healthcare Settings

2020 ◽  
Vol 41 (S1) ◽  
pp. s229-s229
Author(s):  
Hanan Haydar ◽  
Jessica Kumar ◽  
Jennifer Cadnum ◽  
Claudia Hoyen ◽  
Curtis Donskey
Keyword(s):  
Healthcare Facility ◽  
Ease Of Use ◽  
Candida Auris ◽  
Healthcare Settings ◽  
Clostridioides Difficile ◽  
Ultraviolet C ◽  
Submicron Droplets ◽  
High Level ◽  
Healthcare Associated ◽  
Pediatric Healthcare

Background: Toys in playrooms are often shared among patients in pediatric healthcare settings; they can present a risk for transmission of bacterial and viral pathogens. Effective cleaning and disinfection of toys using disinfectant wipes is labor intensive and difficult due to irregular surfaces. Methods: We conducted a point-prevalence culture survey to determine the frequency of contamination of in-use toys and high-touch surfaces in playrooms in a pediatric healthcare facility with methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and Clostridioides difficile. Using a variety of toys inoculated with pathogens, we evaluated efficacy and ease-of-use of 3 novel “no-touch” technologies: (1) an electrostatic sprayer, (2) a small ultraviolet-C (UV-C) box (18.9 × 9.9 × 1.8 inches) for smaller toys, and (3) a high-level disinfection cabinet using ultrasonic submicron droplets of peracetic acid and hydrogen peroxide. Test pathogens included C. difficile, MRSA, and Candida auris. Results: Of 135 items cultured in playrooms, 6 (4.4%) were contaminated with MRSA, 1 (0.7%) was contaminated with VRE, and none were contaminated with C. difficile. Each of the technologies reduced all pathogens by >4 log10 CFU on all types of toys tested (plastic, soft rubber, and tablet). The electrostatic sprayer was considered the easiest to use by all users because large numbers of toys could be processed much more quickly (ie, spray for 20 seconds and allow to air dry) than with disinfectant wipes. The disinfection cabinet required 21 minutes for cycle completion, whereas the decontamination cycle for the UV box was only 30–90 seconds but with limited capacity to hold toys. Conclusions: Three “no-touch” technologies were effective for disinfection of toys contaminated with healthcare-associated pathogens. The electrostatic spray application of disinfectant was considered the easiest to use for rapid decontamination of toys.Funding: NoneDisclosures: None

scholarly journals Evaluation of no-touch technologies for decontamination of toys in pediatric healthcare settings

2021 ◽  
Author(s):  
Hanan Haydar ◽  
Jessica A Kumar ◽  
Jennifer L Cadnum ◽  
Emily Zangla ◽  
Claudia K Hoyen ◽  
...  
Keyword(s):  
Staphylococcus Aureus ◽  
Methicillin Resistant Staphylococcus Aureus ◽  
Methicillin Resistant ◽  
Healthcare Settings ◽  
Clostridioides Difficile ◽  
Bacteriophage Ms2 ◽  
Ultraviolet C ◽  
High Level ◽  
Pediatric Healthcare

Abstract No-touch technologies could be useful to decontaminate shared toys in healthcare settings. A high-level disinfection cSabinet and electrostatic sprayer were effective against methicillin-resistant Staphylococcus aureus (MRSA), bacteriophage MS2, and Clostridioides difficile spores on toys. An ultraviolet-C light box was less effective but reduced MRSA and bacteriophage MS2 by >2 log10.

Clostridioides difficile and Norovirus

2019 ◽  
pp. 123-140
Author(s):  
Thomas J. Sandora
Keyword(s):  
Diagnostic Methods ◽  
Direct Patient Care ◽  
Infectious Dose ◽  
Environmental Cleaning ◽  
Healthcare Settings ◽  
Clostridioides Difficile ◽  
Contaminated Food ◽  
Clinically Significant ◽  
Healthcare Associated ◽  
Pediatric Healthcare

Clostridioides difficile and norovirus are common causes of healthcare-associated gastroenteritis and both organisms cause outbreaks in pediatric healthcare settings. The spores are resistant to routine environmental cleaning with detergents and can survive in the environment for months. C. difficile can easily be transmitted on the hands of healthcare workers, either from direct patient care activities or through contact with a contaminated environment. Norovirus is highly contagious, with an estimated infectious dose as low as 18 viral particles. Transmission occurs either person-to-person or through ingestion of contaminated food and water. This chapter outlines strategies to prevent transmission of healthcare-associated C. difficile and norovirus infections. It includes recommendations for surveillance, isolation, hand hygiene, environmental cleaning and removal of isolation precautions. Diagnostic methods are reviewed, highlighting the challenge of distinguishing between colonization and clinically significant C. difficile infection in young children.

scholarly journals Effectiveness of Ultraviolet-C Room Disinfection on Preventing Healthcare-Associated Clostridioides difficile Infection

2020 ◽  
Vol 41 (S1) ◽  
pp. s33-s33
Author(s):  
Michihiko Goto ◽  
Erin Balkenende ◽  
Gosia Clore ◽  
Rajeshwari Nair ◽  
Loretta Simbartl ◽  
...  
Keyword(s):  
Acute Care ◽  
Acute Care Hospitals ◽  
Incidence Rates ◽  
Positive Test ◽  
Negative Binomial Regression Model ◽  
Test Results ◽  
Clostridioides Difficile ◽  
Ultraviolet C ◽  
Healthcare Associated ◽  
Uv C

Background: Enhanced terminal room cleaning with ultraviolet C (UVC) disinfection has become more commonly used as a strategy to reduce the transmission of important nosocomial pathogens, including Clostridioides difficile, but the real-world effectiveness remains unclear. Objectives: We aimed to assess the association of UVC disinfection during terminal cleaning with the incidence of healthcare-associated C. difficile infection and positive test results for C. difficile within the nationwide Veterans Health Administration (VHA) System. Methods: Using a nationwide survey of VHA system acute-care hospitals, information on UV-C system utilization and date of implementation was obtained. Hospital-level incidence rates of clinically confirmed hospital-onset C. difficile infection (HO-CDI) and positive test results with recent healthcare exposures (both hospital-onset [HO-LabID] and community-onset healthcare-associated [CO-HA-LabID]) at acute-care units between January 2010 and December 2018 were obtained through routine surveillance with bed days of care (BDOC) as the denominator. We analyzed the association of UVC disinfection with incidence rates of HO-CDI, HO-Lab-ID, and CO-HA-LabID using a nonrandomized, stepped-wedge design, using negative binomial regression model with hospital-specific random intercept, the presence or absence of UVC disinfection use for each month, with baseline trend and seasonality as explanatory variables. Results: Among 143 VHA acute-care hospitals, 129 hospitals (90.2%) responded to the survey and were included in the analysis. UVC use was reported from 42 hospitals with various implementation start dates (range, June 2010 through June 2017). We identified 23,021 positive C. difficile test results (HO-Lab ID: 5,014) with 16,213 HO-CDI and 24,083,252 BDOC from the 129 hospitals during the study period. There were declining baseline trends nationwide (mean, −0.6% per month) for HO-CDI. The use of UV-C had no statistically significant association with incidence rates of HO-CDI (incidence rate ratio [IRR], 1.032; 95% CI, 0.963–1.106; P = .65) or incidence rates of healthcare-associated positive C. difficile test results (HO-Lab). Conclusions: In this large quasi-experimental analysis within the VHA System, the enhanced terminal room cleaning with UVC disinfection was not associated with the change in incidence rates of clinically confirmed hospital-onset CDI or positive test results with recent healthcare exposure. Further research is needed to understand reasons for lack of effectiveness, such as understanding barriers to utilization.Funding: NoneDisclosures: None

scholarly journals A Continuously Active Antimicrobial Surface Coating Reduces Bioburden in a Healthcare Setting

2020 ◽  
Vol 41 (S1) ◽  
pp. s439-s439
Author(s):  
Valerie Beck
Keyword(s):  
Surface Coating ◽  
Geometric Mean ◽  
Healthcare Setting ◽  
Aerobic Bacteria ◽  
Healthcare Settings ◽  
Additional Layer ◽  
Clostridioides Difficile ◽  
Sustained Reduction ◽  
Before And After ◽  
Healthcare Associated

Background: It is well known that contaminated surfaces contribute to the transmission of pathogens in healthcare settings, necessitating the need for antimicrobial strategies beyond routine cleaning with momentary disinfectants. A recent publication demonstrated that application of a novel, continuously active antimicrobial surface coating in ICUs resulted in the reduction of healthcare-associated infections. Objective: We determined the general microbial bioburden and incidence of relevant pathogens present in patient rooms at 2 metropolitan hospitals before and after application of a continuously active antimicrobial surface coating. Methods: A continuously active antimicrobial surface coating was applied to patient rooms in intensive care units (ICUs) twice over an 18-month period and in non-ICUs twice over a 6-month study period. The environmental bioburden was assessed 8–16 weeks after each treatment. A 100-cm2 area was swabbed from frequently touched areas in patient rooms: patient chair arm rest, bed rail, TV remote, and backsplash behind the sink. The total aerobic bacteria count was determined for each location by enumeration on tryptic soy agar (TSA); the geometric mean was used to compare bioburden before and after treatment. Each sample was also plated on selective agar for carbapenem-resistant Enterobacteriaceae (CRE), vancomycin-resistant enterococci (VRE), methicillin-resistant Staphylococcus aureus (MRSA), and Clostridioides difficile to determine whether pathogens were present. Pathogen incidence was calculated as the percentage of total sites positive for at least 1 of the 4 target organisms. Results: Before application of the antimicrobial coating, total aerobic bacteria counts in ICUs were >1,500 CFU/100 cm2, and at least 30% of the sites were positive for a target pathogen (ie, CRE, VRE, MRSA or C. difficile). In non-ICUs, the bioburden before treatment was at least 500 CFU/100 cm2, with >50% of sites being contaminated with a pathogen. After successive applications of the surface coating, total aerobic bacteria were reduced by >80% in the ICUs and >40% in the non-ICUs. Similarly, the incidence of pathogen-positive sites was reduced by at least 50% in both ICUs and non-ICUs. Conclusions: The use of a continuously active antimicrobial surface coating provides a significant (P < .01) and sustained reduction in aerobic bacteria while also reducing the occurrence of epidemiologically important pathogens on frequently touched surfaces in patient rooms. These findings support the use of novel antimicrobial technologies as an additional layer of protection against the transmission of potentially harmful bacteria from contaminated surfaces to patients.Funding: Allied BioScience provided Funding: for this study.Disclosures: Valerie Beck reports salary from Allied BioScience.

scholarly journals Risk Factors of Klebsiella pneumoniae Infections in Pediatric Healthcare Settings

2020 ◽  
Vol 19 (2) ◽  
pp. 40-47
Author(s):  
S. A. Kuzmenko ◽  
M. A. Shmakova ◽  
E. B. Brusina
Keyword(s):  
Risk Factors ◽  
Klebsiella Pneumoniae ◽  
Assisted Ventilation ◽  
Antimicrobial Treatment ◽  
Klebsiella Pneumonia ◽  
Healthcare Settings ◽  
Increased Risk ◽  
Healthcare Associated ◽  
Pediatric Healthcare ◽  
Klebsiella Spp

Relevance. Klebsiella pneumoniae is a major cause of severe healthcare-associated infections in children, representing one of the six most widespread multidrug-resistant microorganisms worldwide and requiring the implementation of population-wide treatment strategies.Aim. To study the risk factors for Klebsiella spread in pediatric healthcare settings.Materials and Methods. Here we performed a descriptive retrospective epidemiological study of Klebsiella spp. cases in pediatric units across the entire Kemerovo region (2012–2019). In total, we documented 27,852 treatment outcomes. We further selected 52 confirmed cases and assessed their risk profiles in comparison with 738 condition-matched control children.Results. Average incidence of Klebsiella spp. detection in pediatric healthcare settings was 78.52 per 1,000 patients (95% CI = 75.42–81.74). We revealed a declining incidence of Klebsiella pneumoniae infection in the region, with notable 4-year cyclicity. The proportion of Klebsiella pneumoniae-infected patients increased 2-fold after 5 days of antibiotic therapy. Among the risk factors of Klebsiella pneumonia infection were artificial feeding (OR = 9,21, 95% = 3,31–35,45, р = 0,0001), assisted ventilation (OR = 7,36, 95% CI = 3,92–14,0], р = 0,0001), use of nebulizers (OR = 5,34, 95% CI =2,49 – 10,9], р=0,0001), airway management (OR = 4,62, 95% CI =2,49–8,56, р = 0,0001), preterm birth (OR = 2,55, 95% CI =1,38 – 4,69, р=0,001), low body weight (OR = 2,48, 95% CI = 1,34–4,56, р = 0,002), enema administration (OR = 1,80, 95% CI = 0,78–3,81, р = 0,088), and nasogastric intubation (OR = 1,79, 95% CI = 0,85–3,54, р = 0,065).Conclusions. The incidence of Klebsiella pneumoniae infections is currently lowering and has 4-year cyclicity. Antimicrobial treatment is associated with 2-fold increased risk if administered for ≥ 5 days. A number of healthcare-associated risk factors of Klebsiella pneumoniae infections have been found.

scholarly journals 752. Costs Attributable to Clostridioides difficile Infection in the Presence of Differential Mortality

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S473-S474
Author(s):  
John Sahrmann ◽  
Dustin Stwalley ◽  
Margaret A Olsen ◽  
Holly Yu ◽  
Erik R Dubberke
Keyword(s):  
Healthcare Facility ◽  
Differential Mortality ◽  
Fee For Service ◽  
Research Support ◽  
Cost Estimates ◽  
Clostridioides Difficile ◽  
Clostridioides Difficile Infection ◽  
Parametric Survival Model ◽  
Healthcare Associated ◽  
Community Onset

Abstract Background CDI imposes a major burden on the U.S. healthcare system. Obtaining accurate estimates of economic costs is critical to determining the cost-effectiveness of preventive measures. This task is complicated by differences in epidemiology, mortality, and baseline health status of infected and uninfected individuals, and by the statistical properties of costs data (e.g., right-skewed, excess of zeros costs). Methods Incident CDI cases were identified from Medicare 5% fee-for-service data between 2011 and 2017 and classified into standard surveillance definitions: hospital-onset (HO); other healthcare facility-onset (OHFO); community-onset, healthcare-associated (CO-HCFA); or community-associated (CA). Cases were frequency matched 1:4 to uninfected controls based on age, sex, and year of CDI. Controls were assigned to surveillance definitions based on location at index dates. Medicare allowed costs were summed in 30-day intervals up to 3 years following index. One- and 3-year cumulative costs attributable to CDI were computed using a 3-part estimator consisting of a parametric survival model and a pair of 2-part models predicting costs separately in intervals where death did and did not occur, adjusting for underlying acute and chronic conditions. Results 60,492 CDI cases (Figure 1) were matched to 241,968 controls. Three-year mortality was higher among CDI cases compared to matched controls for HO (45% vs 26%) and OHFO (42% vs 36%), whereas mortality was slightly lower for CDI cases compared to controls for those with community onset (CO-HCFA: 28% vs 32%; CA: 10% vs 11%). One- and 3-year attributable costs due to CDI are shown in Figure 2. Adjusted 1-year attributable costs amounted to &26,954 (95% CI: &26,154–&27,939) for HO; &10,539 (&9,564–&11,518) for OHFO; &6,525 (&5,012–&8,171) for CO-HCFA; and &3,171 (&1,841–&4,200) for CA. Adjusted 3-year attributable costs were &44,736 (&43,063–&46,483) for HO; &13,994 (&12,529–&15,975) for OHFO; &7,349 (&4,738–&10,246) for CO-HCFA; and &2,377 (&166–&4,722) for CA. Figure 1. Proportion of Cases by CDI Surveillance Definitions Abbreviations: HO: hospital-onset; OHFO: other healthcare facility-onset; CO-HCFA: community-onset, healthcare-associated; CA: community-associated. Figure 2. Estimates of Costs Attributable to CDI by CDI Surveillance Definitions at One and Three Years after Onset Top panels: One-year cost estimates. Bottom panels: Three-year cost estimates. Abbreviations: HO: hospital-onset; OHFO: other healthcare facility-onset; CO-HCFA:community-onset, healthcare-associated; CA:community-associated. Conclusion CDI was associated with increased healthcare costs across surveillance definitions in Medicare fee-for-service patients after adjusting for survival and underlying conditions. Disclosures Dustin Stwalley, MA, AbbVie Inc (Shareholder)Bristol-Myers Squibb (Shareholder) Margaret A. Olsen, PhD, MPH, Pfizer (Consultant, Research Grant or Support) Holly Yu, MSPH, Pfizer (Employee) Erik R. Dubberke, MD, MSPH, Ferring (Grant/Research Support)Merck (Consultant)Pfizer (Consultant, Grant/Research Support)Seres (Consultant)Summit (Consultant)

scholarly journals Exploration Of Surface-Programme Relationship As A Basis To Promote Hand Hygiene In Healthcare Waiting Area Setting

2019 ◽  
Vol 266 ◽  
pp. 06011
Keyword(s):  
Hand Hygiene ◽  
Disease Transmission ◽  
Spatial Configuration ◽  
Healthcare Facility ◽  
Technological Advancement ◽  
Healthcare Associated Infection ◽  
Healthcare Settings ◽  
Waiting Area ◽  
New Perspective ◽  
Healthcare Associated

Within a healthcare facility, surface directly correlates with the existing healthcare programme, as it allows the programme to perform in the space. In particular, this surface-programme relationship contributes towards the occurrence of disease transmission as contaminated surfaces have a significant impact on infection potential when healthcare staffs or patients come into contact with these surfaces. This paper presents a preliminary study that explores the spatial layout of a particular healthcare waiting area setting. The surface-programme relationship is analysed to reveal the potential of contact between surface and users. The results of observation and analysis indicated critical areas in the layout where hand hygiene practice becomes essential. It provides a recommendation on how hand hygiene could be promoted through the spatial configuration to prevent the possibility of infection. Overall, this paper gives a new perspective and a better understanding of how to respond to the healthcare-associated infection generally and the industrial demand on technological advancement in healthcare settings specifically.

scholarly journals 1154. Comparison of Five Testing Modalities for the Assessment of Patient Environment Cleanliness

2018 ◽  
Vol 5 (suppl_1) ◽  
pp. S347-S347
Author(s):  
Elizabeth Salsgiver ◽  
Elena Martin ◽  
Katrina Callan ◽  
Niamh B O’Hara ◽  
Rachid Ounit ◽  
...  
Keyword(s):  
Objective Assessment ◽  
Turnaround Time ◽  
Ease Of Use ◽  
Aerobic Culture ◽  
Clostridioides Difficile ◽  
Grant Recipient ◽  
Detection And Counting ◽  
Sensitivity Specificity ◽  
Healthcare Associated ◽  
Organism Identification

Abstract Background Microbial contamination of the patient environment has been associated with healthcare-associated infections. Objective assessment of environmental cleanliness is recommended by the CDC to identify improvement opportunities. Methods currently used to assess cleanliness and microbial dynamics differ in their sensitivity, specificity, cost, ease of use, and turnaround time. We compared five assessment methods to examine these characteristics. Methods The bedrail, overbed table, remote control, and toilet seat in occupied patient rooms were sampled and assessed with: adenosine triphosphate (ATP) luminescence technology (LT), Replicate Organism Detection And Counting (RODAC) plates, C diff Banana Broth™ (CDBB), conventional aerobic culture (CC) and antimicrobial susceptibility testing, and shotgun next-generation sequencing (NGS) and analysis using metagenomic software. Results One hundred forty surfaces from 35 rooms were sampled. Of 70 surfaces sampled by both ATP LT and RODAC, 42 (60%) had concordant “pass” or “fail” results. Of 28 discordant samples, 26 (93%) passed by RODAC but failed by ATP LT. CDBB testing identified Clostridioides difficile on two surfaces in one room; C. difficile was also identified by NGS in this room. NGS had 100% concordance with organisms identified by CC, and identified approximately 20 additional organisms not identified by CC per surface. 38% of organisms identified by NGS were potential pathogens, compared with 13% through CC. No correlations were found between the primary quantitative assessments (RODAC bacterial concentrations and ATP LT ATP concentrations) and quantitative components of CC (presence/absence of organisms) and NGS (read numbers). Conclusion ATP LT and RODAC plates both provide useful quantitative cleanliness data, although high ATP values did not always indicate the The presence of viable aerobic bacteria. CDBB may be a useful method for identifying C. difficile in the environment, but larger studies of the performance characteristics of CDBB are needed. CC and NGS provided useful organism identification information, but NGS had higher sensitivity for detecting potentially pathogenic organisms. The clinical implications of NGS results must be further studied and cost and technical expertise are important considerations. Disclosures N. B. O’Hara, Biotia: Board Member, Employee and Shareholder, Salary. L. F. Westblade, Accelerate Diagnostics: Grant Investigator, Grant recipient. Biomerieux: Grant Investigator, Grant recipient. Allergan: Grant Investigator, Grant recipient. Merck: Grant Investigator, Grant recipient.

scholarly journals Risk of Hospital-Onset C. difficile Infection Increases With Prior Inpatient and Outpatient Visits

2020 ◽  
Vol 41 (S1) ◽  
pp. s78-s79
Author(s):  
Aaron Miller ◽  
Alberto Segre ◽  
Daniel Sewell ◽  
Sriram Pemmaraju ◽  
Philip Polgreen
Keyword(s):  
Substance Abuse ◽  
Nursing Home ◽  
Long Term Care ◽  
Prior Exposure ◽  
Term Care ◽  
Healthcare Settings ◽  
Clostridioides Difficile ◽  
Increased Risk ◽  
Healthcare Associated

Background:Clostridioides difficile is a leading cause of healthcare-associated infections, and greater healthcare exposure is a primary risk factor for Clostridioides difficile infection (CDI). Longer hospital stays and greater CDI pressure, both at the hospital level and the level, have been linked to greater risk. In addition, symptoms associated with healthcare-associated CDI often do not present until a patient has been discharged. Our study objective was to estimate the extent to which exposure to different types of healthcare settings (eg, prior hospitalization, emergency department [ED], outpatient or long-term care) increase risk for hospital-onset CDI. Methods: We conducted a case-control study using the Truven Marketscan Commerical Claims and Medicare Supplemental databases from 2001 to 2017. Case patients were selected as all inpatient visits with a secondary diagnosis of CDI and no previous CDI diagnosis in the prior 90 days. Controls were selected from all inpatient admissions without any CDI diagnosis during the current admission or prior 90 days. A logistic regression model was used to estimate risk associated with prior healthcare exposure. Indicators were created for prior exposure to different healthcare settings: separate indicators were used to indicate transfer, exposure to that setting in the prior 1–30 days, 31–60 days and 61–90 days. Separate indicators were created for prior hospitalization, ED, outpatient clinic, nursing home or long-term care facilities (LTCFs), psychiatric or substance-abuse facility or other outpatient facility. We also included an indicator for prior exposure to a family member with CDI and prior outpatient antibiotics. Results: Estimates for selected variables (odds ratios) are presented in Table 1. Prior hospitalization, ED visits, outpatient clinics, nursing home and LTCFs were all associated with increased risk of secondary diagnosed CDI. Prior hospitalization and nursing home/LTCF conveyed the greatest risk. In addition, a ‘dose-–response’ relationship occurred for each of these exposure settings, with exposure nearest the admission date having the largest risk. Prior exposure to psychiatric , substance abuse, or other outpatient facilities were not risk factors for CDI. Having a family member with prior CDI and both low-risk and high-risk outpatient antibiotics were associated with increased risk. These factors also exhibited a ‘dose–response’ pattern. Conclusions: Exposure to various healthcare settings significantly increased risk for secondary CDI. Prior healthcare exposures occurring nearest to the point of admission conveyed the greatest risk. These results suggest that many hospital-associated CDI cases attributed to a current hospital stay may actually be acquired from prior healthcare settings.Funding: CDC Modeling Infectious Diseases (MInD) in Healthcare NetworkDisclosures: None

scholarly journals Effects of Antibiotic Cycling Policy on Incidence of Healthcare-Associated MRSA and Clostridioides difficile Infection in Secondary Healthcare Settings

2019 ◽  
Vol 25 (1) ◽  
pp. 52-62 ◽  
Author(s):  
Geraldine Mary Conlon-Bingham ◽  
Mamoon Aldeyab ◽  
Michael Scott ◽  
Mary Patricia Kearney ◽  
David Farren ◽  
...  
Keyword(s):  
Healthcare Settings ◽  
Clostridioides Difficile ◽  
Clostridioides Difficile Infection ◽  
Antibiotic Cycling ◽  
Healthcare Associated
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