Mixed-Methods Pilot Study to Assess Perceptions of Antimicrobial Stewardship in Nursing Homes.

OBJECTIVES: To identify features of community nursing home (NH) environments associated with lower rates of overall antibiotic use. DESIGN: This pilot study used an explanatory sequential design that incorporated comparative feedback about antibiotic use to inform a discussion about antimicrobial stewardship practices in community NHs. SETTING: NHs. PARTICIPANTS: Clinical leadership of five NHs. MEASUREMENTS: For the quantitative phase, the number of antibiotic prescriptions, length of therapy, and days of therapy/1,000 days of care were measured at six NHs. For the qualitative phase, semistructured interviews were conducted with healthcare workers in leadership positions at five community NHs. Transcripts from the recorded interviews were assessed using emergent thematic analysis. For the triangulation phase, themes from the semistructured interviews were evaluated in the context of each NH's antibiotic use. RESULTS: The number of antibiotic prescriptions ranged from 172 to 1,244, with 50% to 83% written for 7 days or fewer. All NHs reported a similar proportion of fluoroquinolone use (27-32% of days of therapy). Triangulation yielded six themes for which the environment at each facility ranged from less- to more-supportive antimicrobial stewardship: practice patterns, external influences, infection control, leadership, communication, and facility culture. All NHs reported pressure from well-intentioned family members to prescribe antibiotics. NHs with shorter lengths of therapy and lower overall antibiotic use were consonant with an environment more supportive of antimicrobial stewardship. CONCLUSION: These findings suggest several features of NHs that are supportive of antimicrobial stewardship: practice patterns grounded in established diagnostic criteria, proactive infection control and prevention, open communication and interconnectedness among staff.

A Virtual Clinic Improves Pneumococcal Vaccination for Asplenic Veterans at High Risk for Pneumococcal Disease.

We developed a "virtual clinic" to improve pneumococcal vaccination among asplenic adults. Using an electronic medical record, we identified patients, assessed their vaccination status, entered orders, and notified patients and providers. Within 180 days, 38 of 76 patients (50%) received a pneumococcal vaccination. A virtual clinic may optimize vaccinations among high-risk patients.

Treated hypotension is associated with neonatal morbidity and hearing loss in extremely low birth weight infants.

BACKGROUND: Neonatal hypotension may be a risk factor for neurologic impairment. Few studies have examined the impact of low blood pressure in extremely low birth weight (ELBW) infants weighing 400 to 999 g on neurodevelopmental outcome. OBJECTIVES: We set out to explore the relationship between treated hypotension in the first 72 hours of life and perinatal factors, morbidity, and mortality in ELBW infants and then to compare neurosensory outcome in ELBW infants with treated hypotension and those who never received treatment for hypotension. DESIGN/METHODS: We performed chart review of all 156 ELBW infants admitted to our level III NICU in 1998-1999. Infants had "treated hypotension" if they received fluid pushes, corticosteroids, and/or vasopressors during the first 72 hours of life in an attempt to increase blood pressure. Follow-up included neurologic examination, Bayley Scales of Infant Development, vision and hearing evaluation. Statistical analysis was performed by using SPSS 11.0. Univariate and multivariate analyses were conducted to determine morbidities associated with treated hypotension. RESULTS: Fifty-nine infants received treatment for hypotension. Ninety-seven infants did not. The groups had similar race, gender, delivery mode, chorioamnionitis, and maternal socioeconomic status. Thirty-eight (24%) infants expired, including 20 who received treatment for hypotension. Of the 156 infants in the study group, 110 underwent neurodevelopment testing, and 103 were able to undergo complete neurodevelopment testing and Bayley examination. Multivariate analysis controlling for socioeconomic status and neonatal morbidity revealed that treated hypotension is associated with delayed motor development and hearing loss. CONCLUSIONS: Treated hypotension in ELBW infants in the first 72 hours of life is associated with significant short-term and long-term morbidity. Infants with treated hypotension are more likely to have delayed motor development, hearing loss, and death.