Antibiotic prophylaxis with urodynamic studies in spinal cord injury: Assessing practice patterns and outcomes to guide future practice in a single center.

CONTEXT/OBJECTIVE: Despite urinary tract infections (UTIs) being a common problem in patients with spinal cord injuries (SCIs), and a well-known complication of invasive urologic procedures, little consensus exists regarding the standard of care for peri-procedural antibiotic use for SCI patients undergoing urodynamics studies (UDS). Our research seeks to evaluate local antibiotic prophylaxis pattern in SCI patients undergoing UDS, assess incidence of post-procedural UTI, describe local antibiotic resistance trends, and provide antibiotic stewardship considerations to guide future practice. DESIGN/SETTING/PARTICIPANTS: Retrospective cohort study of SCI patients undergoing UDS from January 2010 to January 2020 at a Veterans Affairs SCI Center. Data on patient demographics, UTI risk factors, pre-procedural urinalysis and culture, and peri-procedural antibiotics was extracted. Incidence of post-procedural UTI was tabulated. Findings were summarized using descriptive statistics. RESULTS: 331 patients were studied. Pre-procedural urine culture was done in 73% of cases, with positive results in 49%. E. coli was the most commonly isolated organism (19%). Antibiotics were used in 86% of cases, 26% of which had a negative culture. A onetime dose of intramuscular gentamicin given immediately pre-procedure was the most common practice (53%; N = 152). No cases of post-procedural UTIs were identified during the study period. CONCLUSION: No post-UDS UTIs occurred under current local practice where most patients received a one-time dose of intramuscular gentamicin as prophylaxis. Though routine gentamicin prophylaxis may play a role in reducing UTI incidence, the low rate of post-UDS UTI in this population, including patients with positive cultures who received no antibiotics, suggests the possibility of refining practice patterns to improve antibiotic stewardship.

Impact of routine urine cultures on antibiotic usage in those undergoing a routine annual spinal cord injury evaluation.

OBJECTIVE: The Veterans Health Administration (VHA), the largest single provider of spinal cord injury and disorder (SCI/D) care in the United States, currently mandates that every patient receives a screening urine culture during the annual evaluation, a yearly comprehensive history and physical examination. This testing has shown in a small subset of patients to overidentify asymptomatic bacteriuria that is then inappropriately treated with antibiotics. The objective of the current analysis was to assess the association of the annual evaluation on urine testing and antibiotic treatment in a national sample of Veterans with SCI/D. DESIGN/METHOD: A retrospective cohort study using national VHA electronic health record data of Veterans with SCI/D seen between October 1, 2017-September 30, 2019 for their annual evaluation. RESULTS: There were 9447 Veterans with SCI/D who received an annual evaluation; 5088 (54%) had a urine culture obtained. 2910 cultures (57%) were positive; E. coli was the most common organism obtained (12.9% of total urine cultures). Of the patients with positive urine cultures, 386 were prescribed antibiotics within the 7 days after that encounter (13%); of the patients with negative cultures (n = 2178), 121 (6%) were prescribed antibiotics; thus, a positive urine culture was a significant driver of antibiotic use (p < 0.001). CONCLUSION: The urine cultures ordered at the annual exam are often followed by antibiotics; this practice may be an important target for antibiotic stewardship programs in SCI.

Diagnosis and management of cardiometabolic disease after spinal cord injury: Identifying gaps in physician training and practices.

CONTEXT: Cardiometabolic disease (CMD) frequently occurs in individuals with spinal cord injury (SCI), with growing awareness surrounding the expansive scope of this problem. As CMD has significant morbidity and mortality, early guidelines-based screening and management have been established. However, the extent to which these guidelines have been adopted are unclear. OBJECTIVE: Describe physicians' screening and management pattern for CMD in patients with SCI, as compared to SCI-specific CMD screening guidelines, and elucidate variables linked to screening and management patterns. METHODS: SCI medicine-boarded physicians were surveyed on screening timing for CMD following acute SCI, along with their practice pattern and comfort level managing common CMD risk factors. RESULTS: Of the forty-seven SCI medicine physicians that responded, 62% felt the ideal timing for CMD screening is 6 months after the acute injury. Of these same physicians, few were screening for insulin resistance and lipid dysregulation prior to 6 months after injury. In addition, less than half felt comfortable writing new prescriptions for anti-glycemic and anti-lipid medications. Furthermore, no association was found between the amount of CMD education with screening or management patterns. Finally, VA-based providers were more likely to screen for CMD within 6 months of injury and were more comfortable managing/starting anti-glycemic medications and statins. CONCLUSIONS: Despite the presence of SCI-specific CMD guidelines, gaps in screening and management practices still exist, most notably with insulin resistance and lipid dysregulation. VA-based providers generally screen and manage CMD risk factors more effectively, and further CMD education could consider emulating VA training modules.

Telemedicine Use Among Physiatrists During the Early Phase of the COVID-19 Pandemic and Potential for Future Use.

Introduction: With the coronavirus disease 2019 (COVID-19) pandemic causing the need for social distancing, telemedicine saw a significant increase in use to provide routine medical care. As a field, physiatry had already been implementing telemedicine prior to the pandemic. In this study, we characterized the use of telemedicine among physiatrists during the early phase of the COVID-19 pandemic to understand the barriers and facilitators to implementing telemedicine use in the field of physiatry in the future. Methods: Online survey of a cross-sectional sample of physiatrists. Analysis was conducted using logistic regression. Results: One hundred seventy one (n = 171) participants completed the survey. Before the pandemic, only 17.5% of respondents used telemedicine. In the logistic regression, physicians who used a hospital-provided platform were more likely to use telemedicine in the future compared with those who used their own secure platform, conducted a phone visit, and used a non-secure platform or other platforms. The three most popular barriers identified were "inability to complete the physical examination," "patients lack of access to technology," and "patients lack of familiarity with the technology." Discussion: Focus on education on telemedicine functional examination strategies and technology strategies for patients and providers (including addressing the digital divide and hospital-provided secure platforms) are potential targets of implementation strategies for greater telemedicine uptake for physiatrists in the future.

Early insights of the COVID-19 pandemic in the Veterans' Affairs spinal cord injury and disorders population.

STUDY DESIGN: Retrospective cohort. OBJECTIVES: The primary outcome of the study was to identify patient characteristics associated with a positive COVID-19 test. The secondary outcome was to identify patient characteristics associated with mortality from COVID-19. SETTING: Veterans Health Administration (VHA) National Spinal Cord Injury and Disorders (SCI) Registry, created by the National Spinal Cord Injury and Disorders SCI Program Office in March 2020. METHODS: Data was analyzed in the form of descriptive statistics and then subsequent regression analysis was performed. RESULTS: A total of 4,562 persons with SCI were tested for COVID-19 between March and July 2020, and 290 were positive. The study found that African Americans had increased odds of testing positive for COVID-19 (OR 1.53 (1.18-2.00), p < 0.01). Increased age correlated with increased odds of mortality after testing positive for COVID-19 (1.046 (1.003-1.090)). Non-smokers had lower odds of mortality following positive COVID-19 test (0.15 (0.04-0.52)). No association was found between neurologic level of injury (NLI) and positive COVID-19 test or increased mortality. Increased Body Mass Index (BMI) did correlate with positive COVID-19 test but not increased mortality. The case fatality rate for persons with SCI and a positive test for COVID-19 was 12%. CONCLUSIONS: It is important to define the risk factors for patients with SCI to elucidate and mitigate individual and population risks. These risk factors also can play a role in determining the allocation of critical healthcare resources.

Corrigendum: Development of phage cocktails to treat E. coli catheter-associated urinary tract infection and associated biofilms.

[This corrects the article DOI: 10.3389/fmicb.2022.796132.].

Development of Phage Cocktails to Treat E. coli Catheter-Associated Urinary Tract Infection and Associated Biofilms.

High rates of antimicrobial resistance and formation of biofilms makes treatment of Escherichia coli catheter-associated urinary tract infections (CAUTI) particularly challenging. CAUTI affect 1 million patients per year in the United States and are associated with morbidity and mortality, particularly as an etiology for sepsis. Phage have been proposed as a potential therapeutic option. Here, we report the development of phage cocktails that lyse contemporary E. coli strains isolated from the urine of patients with spinal cord injury (SCI) and display strong biofilm-forming properties. We characterized E. coli phage against biofilms in two in vitro CAUTI models. Biofilm viability was measured by an MTT assay that determines cell metabolic activity and by quantification of colony forming units. Nine phage decreased cell viability by >80% when added individually to biofilms of two E. coli strains in human urine. A phage cocktail comprising six phage lyses 82% of the strains in our E. coli library and is highly effective against young and old biofilms and against biofilms on silicon catheter materials. Using antibiotics together with our phage cocktail prevented or decreased emergence of E. coli resistant to phage in human urine. We created an anti-biofilm phage cocktail with broad host range against E. coli strains isolated from urine. These phage cocktails may have therapeutic potential against CAUTI.

Current Approaches in Telehealth and Telerehabilitation for Spinal Cord Injury (TeleSCI).

Purpose of Review: Telehealth and telerehabilitation in spinal cord injury (teleSCI) is a growing field that can improve access to care and improve health outcomes in the spinal cord injury population. This review provides an overview of the recent literature on the topic of teleSCI and provides insights on current evidence, future directions, and considerations when using teleSCI for clinical care. Recent Findings: TeleSCI is used most often for preventive health; management of chronic pain, anxiety, and depression; and rehabilitation-related interventions. As video telehealth becomes mainstream, growth in wearable monitors, bio and neurofeedback mechanisms, and app-based care is expected. Summary: TeleSCI is growing in prevalence, demonstrates positive impact on health outcomes, and requires ongoing study to identify, refine, and implement best practices.

Climate Change and Physiatry: A Call to Proportional and Prospective Action.

ABSTRACT: Through increased temperature-related illness, exposure to wildfire smoke and air pollutants, and more frequent and intense natural disasters, climate change is disproportionately affecting the health of people with disabilities. Although the evidence behind the health effects of climate change is growing, there remain critical research gaps in the physiatric literature that must be addressed. Increased education throughout the medical-education continuum is also needed to prepare physiatrists to address the climate-related health effects impacting their patient populations. Physiatrists and their member organizations should advocate for policies that address climate change with a focus on the unique needs of their patient population and the inclusion of people with disabilities in the policy making process.

A Qualitative Analysis to Understand Perception about Medication-Related Problems among Older Minority Adults in a Historically Black Community.

Older adults taking multiple chronic medications experience an increased risk of adverse drug events and other medication-related problems (MRP). Most current literature on medication management involves researcher-driven intervention, yet few studies investigate patients' understanding of MRP in a diverse community setting. This report investigates patients' perception of MRP and patient-centered strategies among a cohort of the older adult group in a historically Black urban community. The study design is qualitative using structured open-ended questions in a multidisciplinary patient-centered focus group. Patients (age 65 years or older) taking seven or more medications were recruited. The group comprises patients, caregivers, pharmacists, health educators, a physician, and a nurse. Recordings of the group discussion are transcribed verbatim and analyzed using thematic content analysis and categorized by codes developed from the social-ecological model. The group reports patient-provider relationships, previous experience, fear of side effects played important roles in medication adherence. There is an unmet need for medication management education and tools to organize complex medication lists from multiple providers. This study provides important insights into MRP experienced by minority older adults and provided researchers with potential strategies for future interventions.

Coronavirus disease 2019 (COVID-19) research agenda for healthcare epidemiology.

This SHEA white paper identifies knowledge gaps and challenges in healthcare epidemiology research related to coronavirus disease 2019 (COVID-19) with a focus on core principles of healthcare epidemiology. These gaps, revealed during the worst phases of the COVID-19 pandemic, are described in 10 sections: epidemiology, outbreak investigation, surveillance, isolation precaution practices, personal protective equipment (PPE), environmental contamination and disinfection, drug and supply shortages, antimicrobial stewardship, healthcare personnel (HCP) occupational safety, and return to work policies. Each section highlights three critical healthcare epidemiology research questions with detailed description provided in supplementary materials. This research agenda calls for translational studies from laboratory-based basic science research to well-designed, large-scale studies and health outcomes research. Research gaps and challenges related to nursing homes and social disparities are included. Collaborations across various disciplines, expertise and across diverse geographic locations will be critical.

Building Community-Engaged Multidisciplinary Partnerships to Improve Medication Management in Elderly Patients With Multiple Chronic Conditions.

PURPOSE: Many studies in preventing adverse drug events have been researcher-driven, yet few have engaged patients in the development of a project. This project aims to engage minority elderly patients with multiple chronic conditions in the development of research questions and strategies to improve medication safety. METHODS: Elderly patients (≥65 years old) who were prescribed 7 or more chronic medications were recruited through a university-based aging resource network in a historically African American community in Houston, Texas. Patients and a caregiver participated in a multidisciplinary workgroup comprised of a physician, pharmacists, a nurse, health educators, and a social worker. Patients were engaged by utilizing the 4 patient-centered outcomes research engagement principles. The workgroup created a strategic plan, completed an environmental scan, identified research problems, and reviewed current evidence-based approaches in the literature. Workgroup findings were presented to a broader audience within a community town hall setting, and input was collected from a community-wide survey. RESULTS: From April 2018 to July 2018, 3 patients and 1 caregiver participated in 5 multidisciplinary workgroup meetings. A total of 74 seniors attended the town hall meeting, and 69 completed the surveys. The most common drug-related problems among survey participants were doubts about drug advertisements (79%) and drug interactions (70%). Most participants (88%) were more comfortable in receiving face-to-face counseling compared to an app or virtual visits. Findings aided in developing 3 grant proposals. CONCLUSIONS: This narrative provides a roadmap for conducting multidisciplinary, patient-centered participatory research to refine research strategies in minimizing drug-related problems.

Experiences of veterans with spinal cord injury related to annual urine screening and antibiotic use for urinary tract infections.

INTRODUCTION: Antimicrobial-resistant bacterial infections are an increasing public health threat and people with spinal cord injury (SCI) are disproportionally at higher risk. National guidelines concerning urine testing after SCI are conflicting. Unnecessary urine testing in the SCI population (with high asymptomatic bacteriuria prevalence) leads to unnecessary antimicrobial use, propagating resistant infections, especially urinary tract infections (UTIs). OBJECTIVES: (a) Describe UTI antimicrobial adherence in patients with SCI. (b) Explore SCI patient knowledge and attitudes toward current urine testing and treatment practices. DESIGN: Mixed methods. SETTING: Veterans Health Administration (VHA) patients with SCI. PARTICIPANTS: Veterans identified as having SCI seen at a VHA facility nationwide. INTERVENTIONS: N/A. MAIN OUTCOME MEASURES: Self-reported medication adherence, patient beliefs and behaviors toward UTIs and antimicrobial use. RESULTS: A total of 105 Morisky Medication Adherence Scale-8 (MMAS-8) surveys were completed out of 369 distributed surveys (28% response rate). Overall, patients reported high medication adherence (mean score of 7.2/8, with 8 being a perfect adherence score). Ten qualitative interviews were completed. Themes identified include generally high adherence to prescribed antimicrobial courses and high levels of patient satisfaction with current outpatient VHA SCI bladder care. The quantitative findings converge with these themes observed in the qualitative interviews; patients were satisfied with current urine testing and treatment practices. CONCLUSIONS: Veterans with SCI are generally satisfied with their current UTI management and self-report taking antimicrobials for UTIs as prescribed. Veterans with SCI typically report high trust in their SCI providers and value their advice on bladder care management. Therefore, it is imperative for clinicians to provide evidence-based education to patients, as well as ensure that each prescribed course of antibiotics for UTI is clinically necessary. Information from this study will guide an intervention promoting appropriate urine testing and antimicrobial prescription practices by SCI providers.

Health Care Disparities Add Insult to Spinal Cord Injury.

The authors describe the disparities and increased risk of traumatic spinal cord injury Black Americans face because of violence. This article should serve as a realization of these inequities and as a call to action to improve the equity of rehabilitation services in this population to improve outcomes.

COVID-19: Screening and triage challenges in people with disability due to Spinal Cord Injury.

An outbreak of a novel coronavirus disease (COVID-19) that emerged in the Chinese city of Wuhan has rapidly become a global public health pandemic. As of March 2020, the Centers for Disease Control and Prevention (CDC) has described priority levels for testing patients with suspected COVID-19 and information on when to seek medical attention. However, there is a paucity of further guidance for people with spinal cord injury (SCI) who may not present with typical symptoms of COVID-19 due to altered physiology. This may pose challenges with surveillance, risk stratification, and initial management of this vulnerable population. In this point-counterpoint discussion, we outline important differences in presentation along with COVID-19 cases co-morbid with SCI.

Spinal Cord Injury Provider Knowledge and Attitudes Toward Bacteriuria Management and Antibiotic Stewardship.

INTRODUCTION: Bacteriuria, either asymptomatic or urinary tract infection, is common in persons with spinal cord injury or disorder (SCI/D). In the Veterans Health Administration (VHA), conflicting clinical practice guidelines make appropriate bacteriuria management and antibiotic stewardship challenging. OBJECTIVE: To explore SCI/D provider knowledge, attitudes, and teamwork around bacteriuria management during the VHA SCI/D annual examination. DESIGN: Mixed methods. SETTING: VHA SCI/D centers. PARTICIPANTS: SCI/D staff providers and physical medicine and rehabilitation resident physicians. MAIN OUTCOME MEASUREMENTS: Knowledge, safety, and teamwork scores on bacteriuria management using a validated questionnaire. Themes on barriers and facilitators to bacteriuria management during the SCI/D annual exam, and attitudes toward antibiotic stewardship in general. RESULTS: We received 84 responses from 344 distributed surveys, with a response rate of 24%. Thirty percent of all participants endorsed incorrect triggers for obtaining a urine culture (change in urine color, cloudiness, or odor). The type of organism identified on culture drove unnecessary antibiotic use; 57% would treat asymptomatic bacteriuria if caused by extended spectrum beta-lactamase Escherichia coli. There were no significant differences between the median (interquartile range [IQR]) knowledge score of the staff providers (70.6 [58.8-82.4]) and the resident physicians (64.7 [58.8-82.4]), but the teamwork climate scores (P = .02) and safety climate scores (P < .01) were higher among staff providers than among resident physicians. Interview analysis identified how the limited recall of content among SCI/D providers of the guidelines for bacteriuria was a potential barrier to their use but attitudes toward guidelines and antibiotic stewardship initiatives were positive. CONCLUSION: All participants objectively demonstrated actionable gaps in bacteriuria management and expressed uncertainty in their knowledge during qualitative interviews. Through addressing these gaps, we can develop effective antibiotic stewardship programs for the VHA SCI/D system of care.