Association Between Periprosthetic Joint Infection and Mortality Following Primary Total Hip Arthroplasty.

BACKGROUND: Periprosthetic joint infection (PJI) remains a dreaded and unpredictable complication after total hip arthroplasty (THA). In addition to causing substantial morbidity, PJI may contribute to long-term mortality risk. Our objective was to determine the long-term mortality risk associated with PJI following THA. METHODS: This population-based, retrospective cohort study included adult patients (≥18 years old) in Ontario, Canada, who underwent their first primary elective THA for arthritis between April 1, 2002, and March 31, 2021. The primary outcome was death within 10 years after the index THA. Mortality was compared between propensity-score-matched groups (PJI within 1 year after surgery versus no PJI within 1 year after surgery) with use of survival analyses. Patients who died within 1 year after surgery were excluded to avoid immortal time bias. RESULTS: A total of 175,432 patients (95,883 [54.7%] women) with a mean age (and standard deviation) of 67 ± 11.4 years underwent primary THA during the study period. Of these, 868 patients (0.49%) underwent surgery for a PJI of the replaced joint within 1 year after the index procedure. After matching, patients with a PJI within the first year had a significantly higher 10-year mortality rate than their counterparts (11.4% [94 of 827 patients] versus 2.2% [18 of 827 patients]; absolute risk difference, 9.19% [95% confidence interval (CI), 6.81% to 11.6%]; hazard ratio, 5.49 [95% CI, 3.32 to 9.09]). CONCLUSIONS: PJI within 1 year after surgery is associated with over a fivefold increased risk of mortality within 10 years. The findings of this study underscore the importance of prioritizing efforts related to the prevention, diagnosis, and treatment of PJIs. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

SARS-CoV-2 Testing for Asymptomatic Patients with Cancer Prior and during Treatment: A Single Centre Experience.

Patients with cancer are more vulnerable to severe COVID-19. As a result, routine SARS-CoV-2 testing of asymptomatic patients with cancer is recommended prior to treatment. However, there is limited evidence of its clinical usefulness. The objective of this study is to evaluate the value of routine testing of asymptomatic patients with cancer. Asymptomatic patients with cancer attending Odette Cancer Centre (Toronto, ON, Canada) were tested for SARS-CoV-2 prior to and during treatment cycles. Results were compared to positivity rates of SARS-CoV-2 locally and provincially. All 890 asymptomatic patients tested negative. Positivity rates in the province were 1.5%, in hospital were 1.0%, and among OCC's symptomatic cancer patients were 0% over the study period. Given our findings and the low SARS-CoV-2 community positivity rates, we recommend a dynamic testing model of asymptomatic patients that triggers testing during increasing community positivity rates of SARS-CoV-2.

Long-Term Sustainability and Acceptance of Antimicrobial Stewardship in Intensive Care: A Retrospective Cohort Study.

OBJECTIVES: To evaluate long-term uptake of an antimicrobial stewardship audit-and-feedback program along with potential predictors of stewardship suggestions and acceptance across a diverse ICU population. DESIGN: A retrospective cohort study. SETTING: An urban, academic medical institution. PATIENTS: Patients admitted to an ICU who received an antimicrobial stewardship program suggestion between June 2010 and September 2019. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: The antimicrobial stewardship program provided 7,749 antibiotic assessments over the study period and made a suggestion to alter therapy in 2,826 (36%). Factors associated with a higher likelihood of receiving a suggestion to alter therapy included shorter hospital length of stay prior to antimicrobial stewardship program review (odds ratio 1.15 for ≤ 5 d; 95% CI 1.00-1.32), admission to cardiovascular (1.37; 1.06-1.76) or burn surgery (1.88; 1.50-2.36) versus general medicine, and preceding duration of antibiotic use greater than 5 days (1.33; 1.10-1.60). Assessment of aminoglycosides (2.91; 1.85-4.89), carbapenems (1.93; 1.54-2.41), and vancomycin (2.71; 2.19-3.36) versus ceftriaxone was more likely to result in suggestions to alter therapy. The suggestion acceptance rate was 67% (1,895/2,826), which was stable throughout the study period. Admission to a level 3 ICU was associated with higher likelihood of acceptance of suggestions (1.50; 1.14-1.97). Factors associated with lower acceptance rates were admission to burn surgery (0.64; 0.45-0.91), treatment of pneumonia (0.64; 0.42-0.97 for community-acquired and 0.65; 0.44-0.94 for ventilator-acquired), unknown source of infection (0.66; 0.48-0.92), and suggestion types of "narrow spectrum" (0.65; 0.45-0.94), "change formulation of antibiotic" (0.42; 0.27-0.64), or "change agent of therapy" (0.63; 0.40-0.97) versus "change of dose". CONCLUSIONS: An antimicrobial stewardship program implemented over a decade resulted in sustained suggestion and acceptance rates. These findings support the need for a persistent presence of audit-and-feedback over time with more frequent suggestions to alter potentially nephrotoxic agents, increased efforts toward specialized care units, and further work approaching infectious sources that are typically treated without pathogen confirmation and identification.

Severity of coronavirus respiratory tract infections in adults admitted to acute care in Toronto, Ontario.

BACKGROUND: The World Health Organization has highlighted the need for improved surveillance and understanding of the health burden imposed by non-influenza RNA respiratory viruses. Human coronaviruses (CoVs) are a major cause of respiratory and gastrointestinal tract infections with associated morbidity and mortality. OBJECTIVES: The objective of our study was to characterize the epidemiology of CoVs in our tertiary care centre, and identify clinical correlates of disease severity. STUDY DESIGN: A cross-sectional study was performed of 226 patients admitted with confirmed CoV respiratory tract infection between 2010 and 2016. Variables consistent with a severe disease burden were evaluated including symptoms, length of stay, intensive care unit (ICU) admission and mortality. RESULTS: CoVs represented 11.3% of all positive respiratory virus samples and OC43 was the most commonly identified CoV. The majority of infections were community-associated while 21.6% were considered nosocomial. The average length of stay was 11.8 days with 17.3% of patients requiring ICU admission and an all-cause mortality of 7%. In a multivariate model, female gender and smoking were associated with increased likelihood of admission to ICU or death. CONCLUSION: This study highlights the significant burden of CoVs and justifies the need for surveillance in the acute care setting.

Standardisation of perioperative urinary catheter use to reduce postsurgical urinary tract infection: an interrupted time series study.

BACKGROUND: Prevention of healthcare-associated urinary tract infection (UTI) has been the focus of a national effort, yet appropriate indications for insertion and removal of urinary catheters (UC) among surgical patients remain poorly defined. METHODS: We developed and implemented a standardised approach to perioperative UC use to reduce postsurgical UTI including standard criteria for catheter insertion, training of staff to insert UC using sterile technique and standardised removal in the operating room and surgical unit using a nurse-initiated medical directive. We performed an interrupted time series analysis up to 2 years following intervention. The primary outcome was the proportion of patients who developed postsurgical UTI within 30 days as measured by the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). Process measures included monthly UC insertions, removals in the operating room and UC days per patient-days on surgical units. RESULTS: At baseline, 22.5% of patients were catheterised for surgery, none were removed in the operating room and catheter-days per patient-days were 17.4% on surgical units. Following implementation of intervention, monthly catheter removal in the operating room immediately increased (range 12.2%-30.0%) while monthly UC insertion decreased more slowly before being sustained below baseline for 12 months (range 8.4%-15.6%). Monthly catheter-days per patient-days decreased to 8.3% immediately following intervention with a sustained shift below the mean in the final 8 months. Postsurgical UTI decreased from 2.5% (95% CI 2.0-3.1%) to 1.4% (95% CI 1.1-1.9; p=0.002) during the intervention period. CONCLUSIONS: Standardised perioperative UC practices resulted in measurable improvement in postsurgical UTI. These appropriateness criteria for perioperative UC use among a broad range of surgical services could inform best practices for hospitals participating in ACS NSQIP.

Radiation safety in the cardiac catheterization lab: A time series quality improvement initiative.

BACKGROUND: Interventional cardiologists have one of the highest annual radiation exposures yet systems of care that promote radiation safety in cardiac catheterization labs are lacking. This study sought to reduce the frequency of radiation exposure, for PCI procedures, above 1.5Gy in labs utilizing a Phillips system at our local institution by 40%, over a 12-month period. METHODS: We performed a time series study to assess the impact of different interventions on the frequency of radiation exposure above 1.5Gy. Process measures were percent of procedures where collimation and magnification were used and percent of completion of online educational modules. Balancing measures were the mean number of cases performed and mean fluoroscopy time. INTERVENTIONS: Information sessions, online modules, policies and posters were implemented followed by the introduction of a new lab with a novel software (AlluraClarity©) to reduce radiation dose. RESULTS: There was a significant reduction (91%, p<0.05) in the frequency of radiation exposure above 1.5Gy after utilizing a novel software (AlluraClarity©) in a new Phillips lab. Process measures of use of collimation (95.0% to 98.0%), use of magnification (20.0% to 14.0%) and completion of online modules (62%) helped track implementation. The mean number of cases performed and mean fluoroscopy time did not change significantly. CONCLUSION: While educational strategies had limited impact on reducing radiation exposure, implementing a novel software system provided the most effective means of reducing radiation exposure.

Explanation and elaboration of the SQUIRE (Standards for Quality Improvement Reporting Excellence) Guidelines, V.2.0: examples of SQUIRE elements in the healthcare improvement literature.

Since its publication in 2008, SQUIRE (Standards for Quality Improvement Reporting Excellence) has contributed to the completeness and transparency of reporting of quality improvement work, providing guidance to authors and reviewers of reports on healthcare improvement work. In the interim, enormous growth has occurred in understanding factors that influence the success, and failure, of healthcare improvement efforts. Progress has been particularly strong in three areas: the understanding of the theoretical basis for improvement work; the impact of contextual factors on outcomes; and the development of methodologies for studying improvement work. Consequently, there is now a need to revise the original publication guidelines. To reflect the breadth of knowledge and experience in the field, we solicited input from a wide variety of authors, editors and improvement professionals during the guideline revision process. This Explanation and Elaboration document (E&E) is a companion to the revised SQUIRE guidelines, SQUIRE 2.0. The product of collaboration by an international and interprofessional group of authors, this document provides examples from the published literature, and an explanation of how each reflects the intent of a specific item in SQUIRE. The purpose of the guidelines is to assist authors in writing clearly, precisely and completely about systematic efforts to improve the quality, safety and value of healthcare services. Authors can explore the SQUIRE statement, this E&E and related documents in detail at http://www.squire-statement.org.

Reducing antimicrobial therapy for asymptomatic bacteriuria among noncatheterized inpatients: a proof-of-concept study.

This proof-of-concept study demonstrates that no longer routinely reporting urine culture results from noncatheterized medical and surgical inpatients can greatly reduce unnecessary antimicrobial therapy for asymptomatic bacteriuria without significant additional laboratory workload. Larger studies are needed to confirm the generalizability, safety, and sustainability of this model of care.