The use of UV-C radiation for terminal disinfection of pathogenic Gram-negative rods: a pilot study.

In this controlled study, we found that exposure to ultraviolet-C (UV-C) radiation was able to arrest the growth of selected pathogenic enteric and nonfermenting Gram-negative rods. Further studies are needed to confirm the clinical efficacy and determine optimal implementation strategies for utilizing UV-C terminal disinfection.

Association of entry into hospice or palliative care consultation during acute care hospitalization with subsequent antibiotic utilization.

OBJECTIVE: We aimed to estimate antibiotic use during the last 6 months of life for hospitalized patients under hospice or palliative care and identify potential targets (i.e. time points) for antibiotic stewardship during the end-of-life period. METHODS: We conducted a retrospective cohort study of nationwide Veterans Affairs (VA) patients who died between January 1, 2014 and December 31, 2019 and who had been hospitalized within 6 months prior to death. Data from the VA's integrated electronic medical record were collected, including demographics, comorbid conditions, and duration of inpatient antibiotics administered, along with outpatient antibiotics dispensed. A propensity score-matched cohort analysis was conducted to compare antibiotic use between hospitalized patients placed into palliative care or hospice matched to hospitalized patients not receiving palliative care or hospice. RESULTS: There were 9808 and 40 796 propensity score-matched patient pairs in the hospice and palliative care groups, respectively. Within 14 days of placement or consultation, 41% (4040/9808) of hospice patients and 48% (19 735/40 796) of palliative care patients received at least one antibiotic, while 25% (2420/9808) matched nonhospice and 27% (10 991/40 796) matched nonpalliative care patients received antibiotics. Entry into hospice was independently associated with a 12% absolute increase in antibiotic prescribing, and entry into palliative care was associated with a 17% absolute increase during the 14 days post-entry vs. pre-entry period. DISCUSSION: We observed that patients receiving end-of-life care had high levels of antibiotic exposure across this VA population, particularly during admissions when they received hospice or palliative care consultation.

Development of a fully automated surgical site infection detection algorithm for use in cardiac and orthopedic surgery research.

OBJECTIVE: To develop a fully automated algorithm using data from the Veterans' Affairs (VA) electrical medical record (EMR) to identify deep-incisional surgical site infections (SSIs) after cardiac surgeries and total joint arthroplasties (TJAs) to be used for research studies. DESIGN: Retrospective cohort study. SETTING: This study was conducted in 11 VA hospitals. PARTICIPANTS: Patients who underwent coronary artery bypass grafting or valve replacement between January 1, 2010, and March 31, 2018 (cardiac cohort) and patients who underwent total hip arthroplasty or total knee arthroplasty between January 1, 2007, and March 31, 2018 (TJA cohort). METHODS: Relevant clinical information and administrative code data were extracted from the EMR. The outcomes of interest were mediastinitis, endocarditis, or deep-incisional or organ-space SSI within 30 days after surgery. Multiple logistic regression analysis with a repeated regular bootstrap procedure was used to select variables and to assign points in the models. Sensitivities, specificities, positive predictive values (PPVs) and negative predictive values were calculated with comparison to outcomes collected by the Veterans' Affairs Surgical Quality Improvement Program (VASQIP). RESULTS: Overall, 49 (0.5%) of the 13,341 cardiac surgeries were classified as mediastinitis or endocarditis, and 83 (0.6%) of the 12,992 TJAs were classified as deep-incisional or organ-space SSIs. With at least 60% sensitivity, the PPVs of the SSI detection algorithms after cardiac surgeries and TJAs were 52.5% and 62.0%, respectively. CONCLUSIONS: Considering the low prevalence rate of SSIs, our algorithms were successful in identifying a majority of patients with a true SSI while simultaneously reducing false-positive cases. As a next step, validation of these algorithms in different hospital systems with EMR will be needed.

Antibiotic use during end-of-life care: A systematic literature review and meta-analysis.

BACKGROUND: We performed a systematic literature review and meta-analysis measuring the burden of antibiotic use during end-of-life (EOL) care. METHODS: We searched PubMed, CINAHL (EBSCO platform), and Embase (Elsevier platform), through July 2019 for studies with the following inclusion criteria in the initial analysis: antibiotic use in the EOL care patients (advanced dementia, cancer, organ failure, frailty or multi-morbidity). If the number of patients in palliative care consultation (PCC) was available, antibiotic use data were pooled to compare the proportion of patients who received antibiotics under PCC compared to those not receiving PCC. Random-effect models were used to obtain pooled mean differences, and heterogeneity was assessed using the I2 value. RESULTS: Overall, 72 studies met the inclusion criteria and were included in the final review: 22 EOL studies included only patients with cancer; 17 studies included only patients with advanced dementia; and 33 studies included "mixed populations" of EOL patients. Although few studies reported antibiotic using standard metrics (eg, days of therapy), 48 of 72 studies (66.7%) reported antibiotic use in >50% of all patients. When the 3 studies that evaluated antibiotic use in PCC were pooled together, patients under PCC was more likely to receive antibiotics compared to patients not under PCC (pooled odds ratio, 1.73; 95% CI, 1.02-2.93). CONCLUSIONS: Future studies are needed to evaluate the benefits and harms of using antibiotics for patients during EOL care in diverse patient populations.

Risk of Recurrent Staphylococcus aureus Prosthetic Joint Infection in Rheumatoid Arthritis Patients-A Nationwide Cohort Study.

BACKGROUND: Treatment of rheumatoid arthritis (RA) often involves immune-suppressive therapies. Concern for recurrent prosthetic joint infection (PJI) in RA patients might be high and could reduce use of joint implantation in these patients. We aimed to evaluate the risk of recurrence of PJI in RA patients compared with osteoarthritis (OA) patients by utilizing a large health care system. METHODS: We conducted a retrospective cohort study of all patients admitted for a Staphylococcus aureus PJI who underwent debridement, antibiotics, and implant retention (DAIR) or 2-stage exchange (2SE) between 2003 and 2010 at 86 Veterans Affairs Medical Centers. Both RA patients and the comparison group of osteoarthritis (OA) patients were identified using International Classification of Diseases, Ninth Revision, codes. All index PJI and recurrent positive cultures for S. aureus during 2 years of follow-up were validated by manual chart review. A Cox proportional hazards regression model was used to compare the time to recurrent PJI for RA vs OA. RESULTS: In our final cohort of 374 veterans who had either DAIR or 2SE surgery for their index S. aureus PJI, 11.2% had RA (n = 42). The majority of the cohort was male (97.3%), and 223 (59.6%) had a methicillin-susceptible S. aureus PJI. RA patients had a similar risk of failure compared with OA patients, after adjusting for covariates (hazard ratio, 0.81; 95% confidence interval, 0.48-1.37). CONCLUSIONS: Prior diagnosis of RA does not increase the risk of recurrent S. aureus PJI. Further studies are needed to evaluate the effect of different RA therapies on outcomes of episodes of PJI.

The Value of Electronically Extracted Data for Auditing Outpatient Antimicrobial Prescribing.

OBJECTIVE The optimal approach to auditing outpatient antimicrobial prescribing has not been established. We assessed how different types of electronic data-including prescriptions, patient-visits, and International Classification of Disease, Tenth Revision (ICD-10) codes-could inform automated antimicrobial audits. DESIGN Outpatient visits during 2016 were retrospectively reviewed, including chart abstraction, if an antimicrobial was prescribed (cohort 1) or if the visit was associated with an infection-related ICD-10 code (cohort 2). Findings from cohorts 1 and 2 were compared. SETTING Primary care clinics and the emergency department (ED) at the Iowa City Veterans Affairs Medical Center. RESULTS In cohort 1, we reviewed 2,353 antimicrobial prescriptions across 52 providers. ICD-10 codes had limited sensitivity and positive predictive value (PPV) for validated cases of cystitis and pneumonia (sensitivity, 65.8%, 56.3%, respectively; PPV, 74.4%, 52.5%, respectively). The volume-adjusted antimicrobial prescribing rate was 13.6 per 100 ED visits and 7.5 per 100 primary care visits. In cohort 2, antimicrobials were not indicated in 474 of 851 visits (55.7%). The antimicrobial overtreatment rate was 48.8% for the ED and 59.7% for primary care. At the level of the individual prescriber, there was a positive correlation between a provider's volume-adjusted antimicrobial prescribing rate and the individualized rates of overtreatment in both the ED (r=0.72; P<.01) and the primary care setting (r=0.82; P=0.03). CONCLUSIONS In this single-center study, ICD-10 codes had limited sensitivity and PPV for 2 infections that typically require antimicrobials. Electronically extracted data on a provider's rate of volume-adjusted antimicrobial prescribing correlated with the frequency at which unnecessary antimicrobials were prescribed, but this may have been driven by outlier prescribers. Infect Control Hosp Epidemiol 2018;39:64-70.

Frequency of Adverse Events Before, During, and After Hospital Admission.

OBJECTIVES: Adverse events (AEs) are unintended physical injuries resulting from or contributed to by medical or surgical care. We determined the frequency and type of AEs before, during, and after hospital admission. METHODS: We conducted a cohort study of 296 adult hospital patients. We used the standardized Institute for Healthcare Improvement Global Trigger Tool for Measuring Adverse Events to review the medical records of the hospital patients for occurrence, timing relative to hospital admission, severity, and preventability of AEs. We also identified the primary physiologic system affected by the AE. RESULTS: Among 296 patients, we identified 338 AEs. AEs occurred with similar frequency before (n = 148; 43.8%) and during hospital admission (n = 162; 47.9%). Fewer AEs occurred after discharge (n = 28; 8.3%). Half of all AEs (n = 169; 50.0%) were severe, whereas 47.9% (n = 162) were preventable. CONCLUSIONS: AEs occur with similar frequency before and during hospitalization and may contribute more to hospital admissions than previously recognized. These findings suggest that efforts to improve patient safety should include outpatient settings in addition to the more commonly targeted acute care settings.

Association of a bundled intervention with surgical site infections among patients undergoing cardiac, hip, or knee surgery.

IMPORTANCE: Previous studies suggested that a bundled intervention was associated with lower rates of Staphylococcus aureus surgical site infections (SSIs) among patients having cardiac or orthopedic operations. OBJECTIVE: To evaluate whether the implementation of an evidence-based bundle is associated with a lower risk of S. aureus SSIs in patients undergoing cardiac operations or hip or knee arthroplasties. DESIGN, SETTING, AND PARTICIPANTS: Twenty hospitals in 9 US states participated in this pragmatic study; rates of SSIs were collected for a median of 39 months (range, 39-43) during the preintervention period (March 1, 2009, to intervention) and a median of 21 months (range, 14-22) during the intervention period (from intervention start through March 31, 2014). INTERVENTIONS: Patients whose preoperative nares screens were positive for methicillin-resistant S. aureus (MRSA) or methicillin-susceptible S. aureus (MSSA) were asked to apply mupirocin intranasally twice daily for up to 5 days and to bathe daily with chlorhexidine-gluconate (CHG) for up to 5 days before their operations. MRSA carriers received vancomycin and cefazolin or cefuroxime for perioperative prophylaxis; all others received cefazolin or cefuroxime. Patients who were MRSA-negative and MSSA-negative bathed with CHG the night before and morning of their operations. Patients were treated as MRSA-positive if screening results were unknown. MAIN OUTCOMES AND MEASURES: The primary outcome was complex (deep incisional or organ space) S. aureus SSIs. Monthly SSI counts were analyzed using Poisson regression analysis. RESULTS: After a 3-month phase-in period, bundle adherence was 83% (39% full adherence; 44% partial adherence). Overall, 101 complex S. aureus SSIs occurred after 28,218 operations during the preintervention period and 29 occurred after 14,316 operations during the intervention period (mean rate per 10,000 operations, 36 for preintervention period vs 21 for intervention period, difference, -15 [95% CI, -35 to -2]; rate ratio [RR], 0.58 [95% CI, 0.37 to 0.92]). The rates of complex S. aureus SSIs decreased for hip or knee arthroplasties (difference per 10,000 operations, -17 [95% CI, -39 to 0]; RR, 0.48 [95% CI, 0.29 to 0.80]) and for cardiac operations (difference per 10,000 operations, -6 [95% CI, -48 to 8]; RR, 0.86 [95% CI, 0.47 to 1.57]). CONCLUSIONS AND RELEVANCE: In this multicenter study, a bundle comprising S. aureus screening, decolonization, and targeted prophylaxis was associated with a modest, statistically significant decrease in complex S. aureus SSIs.

Costs Associated With Surgical Site Infections in Veterans Affairs Hospitals.

IMPORTANCE: Surgical site infections (SSIs) are potentially preventable complications that are associated with excess morbidity and mortality. OBJECTIVE: To determine the excess costs associated with total, deep, and superficial SSIs among all operations and for high-volume surgical specialties. DESIGN, SETTING, AND PARTICIPANTS: Surgical patients from 129 Veterans Affairs (VA) hospitals were included. The Veterans Health Administration Decision Support System and VA Surgical Quality Improvement Program databases were used to assess costs associated with SSIs among VA patients who underwent surgery in fiscal year 2010. MAIN OUTCOMES AND MEASURES: Linear mixed-effects models were used to evaluate incremental costs associated with SSIs, controlling for patient risk factors, surgical risk factors, and hospital-level variation in costs. Costs of the index hospitalization and subsequent 30-day readmissions were included. Additional analysis determined potential cost savings of quality improvement programs to reduce SSI rates at hospitals with the highest risk-adjusted SSI rates. RESULTS: Among 54,233 VA patients who underwent surgery, 1756 (3.2%) experienced an SSI. Overall, 0.8% of the cohort had a deep SSI, and 2.4% had a superficial SSI. The mean unadjusted costs were $31,580 and $52,620 for patients without and with an SSI, respectively. In the risk-adjusted analyses, the relative costs were 1.43 times greater for patients with an SSI than for patients without an SSI (95% CI, 1.34-1.52; difference, $11,876). Deep SSIs were associated with 1.93 times greater costs (95% CI, 1.71-2.18; difference, $25,721), and superficial SSIs were associated with 1.25 times greater costs (95% CI, 1.17-1.35; difference, $7003). Among the highest-volume specialties, the greatest mean cost attributable to SSIs was $23,755 among patients undergoing neurosurgery, followed by patients undergoing orthopedic surgery, general surgery, peripheral vascular surgery, and urologic surgery. If hospitals in the highest 10th percentile (ie, the worst hospitals) reduced their SSI rates to the rates of the hospitals in the 50th percentile, the Veterans Health Administration would save approximately $6.7 million per year. CONCLUSIONS AND RELEVANCE: Surgical site infections are associated with significant excess costs. Among analyzed surgery types, deep SSIs and SSIs among neurosurgery patients are associated with the highest risk-adjusted costs. Large potential savings per year may be achieved by decreasing SSI rates.

Epidemiology of methicillin-resistant Staphylococcus aureus carriage and MRSA surgical site infections in patients undergoing colorectal surgery: a cohort study in two centers.

BACKGROUND: Surgical site infections (SSIs) after colorectal surgery usually are caused by commensal intestinal bacteria. Methicillin-resistant Staphylococcus aureus (MRSA) may be responsible for additional SSI-related morbidity. The aim of this retrospective cohort study was to describe the epidemiology of SSIs caused by MRSA after colorectal surgery in two tertiary-care centers, one in Geneva, Switzerland (G), and the other in Chicago, Illinois (C). METHODS: Adult patients undergoing colorectal resections during periods of universal screening for MRSA on admission were identified retrospectively. Demographic characteristics, surgery-related factors, and occurrence of MRSA SSI were compared in patients with and without MRSA carriage before surgery. RESULTS: There were 1,069 patients (G=194, C=875) with a median age of 67 years fulfilling the inclusion criteria. Of these, 45 patients (4.2%) had a positive MRSA screening result within 30 days before surgery (G=18, C=27; p<0.001). Ten patients (0.9%; G=6, C=4) developed MRSA SSI, detected a median of 17.5 days after surgery, but only two of them were MRSA-positive before surgery. Nine of the 45 MRSA carriers identified by screening received pre-operative prophylaxis with vancomycin (G 6/18, C 3/27), and 17 of these patients (37.8%; G 7/18, C 10/27) were started on MRSA decolonization therapy before surgery. Pre-operative administration of either decolonization or vancomycin was not protective against MRSA SSI (p=0.49). CONCLUSION: Methicillin-resistant S. aureus seems to be an infrequent cause of SSI after colorectal resections, even in MRSA carriers. Systematic universal screening for MRSA carriage prior to colorectal surgery may not be beneficial for the individual patient. Post-operative factors seem to be important in MRSA infections, as the majority of MRSA SSIs occurred in patients negative for MRSA carriage.

The impact of Contact Isolation on the quality of inpatient hospital care.

BACKGROUND: Contact Isolation is a common hospital infection prevention method that may improve infectious outcomes but may also hinder healthcare delivery. METHODS: To evaluate the impact of Contact Isolation on compliance with individual and composite process of care quality measures, we formed four retrospective diagnosis-based cohorts from a 662-bed tertiary-care medical center. Each cohort contained patients evaluated for one of four Centers for Medicare and Medicaid Services (CMS) Hospital Compare process measures including Acute Myocardial Infarction (AMI), Congestive Heart Failure (CHF), Pneumonia (PNA) and Surgical Care Improvement Project (SCIP) from January 1, 2007 through May 30, 2009. RESULTS: The 6716-admission cohort included 1259 with AMI, 834 with CHF, 1377 with PNA and 3246 in SCIP. Contact Isolation was associated with not meeting 4 of 23 individual hospital measures (4 of 10 measures were not met for care provided while patients are typically isolated). Contact Isolation was independently associated with lower compliance with the composite pneumonia process-of-care measure (OR 0.3, 95% CI 0.1-0.7). AMI, CHF and SCIP composite measures were not impacted by Contact Isolation. CONCLUSIONS: Contact Isolation was associated with lower adherence to some pneumonia quality of care process measures of care on inpatient wards but did not impact CHF, AMI or SCIP measures.

Targeted surveillance of methicillin-resistant Staphylococcus aureus and its potential use to guide empiric antibiotic therapy.

The present study aimed to determine the frequency of methicillin-resistant Staphylococcus aureus (MRSA)-positive clinical culture among hospitalized adults in different risk categories of a targeted MRSA active surveillance screening program and to assess the utility of screening in guiding empiric antibiotic therapy. We completed a prospective cohort study in which all adults admitted to non-intensive-care-unit locations who had no history of MRSA colonization or infection received targeted screening for MRSA colonization upon hospital admission. Anterior nares swab specimens were obtained from all high-risk patients, defined as those who self-reported admission to a health care facility within the previous 12 months or who had an active skin infection on admission. Data were analyzed for the subcohort of patients in whom an infection was suspected, determined by (i) receipt of antibiotics within 48 h of admission and/or (ii) the result of culture of a sample for clinical analysis (clinical culture) obtained within 48 h of admission. Overall, 29,978 patients were screened and 12,080 patients had suspected infections. A total of 46.4% were deemed to be at high risk on the basis of the definition presented above, and 11.1% of these were MRSA screening positive (colonized). Among the screening-positive patients, 23.8% had a sample positive for MRSA by clinical culture. Only 2.4% of patients deemed to be at high risk but found to be screening negative had a sample positive for MRSA by clinical culture, and 1.6% of patients deemed to be at low risk had a sample positive for MRSA by clinical culture. The risk of MRSA infection was far higher in those who were deemed to be at high risk and who were surveillance culture positive. Targeted MRSA active surveillance may be beneficial in guiding empiric anti-MRSA therapy.

Clinical and economic outcomes attributable to health care-associated sepsis and pneumonia.

BACKGROUND: Health care-associated infections affect 1.7 million hospitalizations each year, but the clinical and economic costs attributable to these infections are poorly understood. Reliable estimates of these costs are needed to efficiently target limited resources for the greatest public health benefit. METHODS: Hospital discharge records from the Nationwide Inpatient Sample database were used to identify sepsis and pneumonia cases among 69 million discharges from hospitals in 40 US states between 1998 and 2006. Community-acquired infections were excluded using criteria adapted from previous studies. Because these criteria may not exclude all community-acquired infections, outcomes were examined separately for cases associated with invasive procedures, which were unlikely to result from preexisting infections. Attributable hospital length of stay, hospital costs, and crude in-hospital mortality were estimated from discharge records using a multivariate matching analysis and a supplementary regression analysis. These models controlled for patient diagnoses, procedures, comorbidities, demographics, and length of stay before infection. RESULTS: In cases associated with invasive surgery, attributable mean length of stay was 10.9 days, costs were $32 900, and mortality was 19.5% for sepsis; corresponding values for pneumonia were 14.0 days, $46 400, and 11.4%, respectively (P < .001). In cases not associated with invasive surgery, attributable mean length of stay, costs, and mortality were estimated to be 1.9 to 6.0 days, $5800 to $12 700, and 11.7% to 16.0% for sepsis and 3.7 to 9.7 days, $11 100 to $22 300, and 4.6% to 10.3% for pneumonia (P < .001). CONCLUSION: Health care-associated sepsis and pneumonia impose substantial clinical and economic costs.

Impact of admission hyperglycemia on hospital mortality in various intensive care unit populations.

OBJECTIVE: Hyperglycemia in intensive care unit patients has been associated with an increased mortality rate, and institutions have already begun tight glucose control programs based on a limited number of clinical trials in restricted populations. This study aimed to assess the generalizability of the association between hyperglycemia and in-hospital mortality in different intensive care unit types adjusting for illness severity and diabetic history. DESIGN: Retrospective cohort study. SETTING: The medical, cardiothoracic surgery, cardiac, general surgical, and neurosurgical intensive care units of the University of Maryland Medical Center. PATIENTS: Patients admitted between July 1996 and January 1998 with length of stay > or = 24 hrs (n = 2713). INTERVENTIONS: On intensive care unit admission, blood glucose and other physiologic variables were evaluated. Regular measurements were taken for calculation of Acute Physiology and Chronic Health Evaluation III scoring. Patients were followed through hospital discharge. Admission blood glucose was used to classify patients as hyperglycemic (> 200 mg/dL) or normoglycemic (60-200 mg/dL). The contribution of hyperglycemia to in-hospital mortality stratified by intensive care unit type and diabetes history while controlling for illness severity was estimated by logistic regression. MEASUREMENTS AND MAIN RESULTS: The adjusted odds ratios for death comparing all patients with hyperglycemia to those without were 0.81 (95% confidence interval, 0.37, 1.77) and 1.76 (95% confidence interval, 1.23, 2.53) for those with and without diabetic history, respectively. Higher mortality was seen in hyperglycemic patients without diabetic history in the cardiothoracic, (adjusted odds ratio, 2.84 [1.21, 6.63]), cardiac (adjusted odds ratio, 2.64 [1.14, 6.10]), and neurosurgical units (adjusted odds ratio, 2.96 [1.51, 5.77]) but not the medical or surgical intensive care units or in patients with diabetic history. CONCLUSIONS: The association between hyperglycemia on intensive care unit admission and in-hospital mortality was not uniform in the study population; hyperglycemia was an independent risk factor only in patients without diabetic history in the cardiac, cardiothoracic, and neurosurgical intensive care units.

Health and economic impact of surgical site infections diagnosed after hospital discharge.

Although surgical site infections (SSIs) are known to cause substantial illness and costs during the index hospitalization, little information exists about the impact of infections diagnosed after discharge, which constitute the majority of SSIs. In this study, using patient questionnaire and administrative databases, we assessed the clinical outcomes and resource utilization in the 8-week postoperative period associated with SSIs recognized after discharge. SSI recognized after discharge was confirmed in 89 (1.9%) of 4,571 procedures from May 1997 to October 1998. Patients with SSI, but not controls, had a significant decline in SF-12 (Medical Outcomes Study 12-Item Short-Form Health Survey) mental health component scores after surgery (p=0.004). Patients required significantly more outpatient visits, emergency room visits, radiology services, readmissions, and home health aide services than did controls. Average total costs during the 8 weeks after discharge were US dollars 5,155 for patients with SSI and US dollars 1,773 for controls (p<0.001).