Electronic medical record-based deep data cleaning and phenotyping improve the diagnostic validity and mortality assessment of infective endocarditis: medical big data initiative of CMUH.

BACKGROUND: International Classification of Diseases (ICD) code-based claims databases are often used to study infective endocarditis (IE). However, the quality of ICD coding can influence the reliability of IE research. The impact of complementing the ICD-only approach with data extracted from electronic medical records (EMRs) has yet to be explored. METHODS: We selected the information of adult patients with discharge ICD codes for IE (ICD-9: 421, 112.81, 036.42, 098.84, 115.04, 115.14, 115.94, 424.9; ICD-10: I33, I38, I39) during 2005-2016 in China Medical University Hospital. Data extraction was conducted on the basis of the modified Duke criteria to establish a reference group comprising patients with definite or possible IE. Clinical characteristics and in-hospital mortality were compared between ICD-identified and Duke-confirmed cases. The positive predictive value (PPV) was used to quantify the IE identification performance of various phenotyping algorithms. RESULTS: A total of 593 patients with discharge ICD codes for IE were identified, only 56.7% met the modified Duke criteria. The crude in-hospital mortality for Duke-confirmed and Duke-rejected IE were 24.4% and 8.2%, respectively. The adjusted in-hospital mortality for ICD-identified IE was lower than that for Duke-confirmed IE by a difference of 5.1%. The best PPV was achieved (0.90, 95% CI 0.86-0.93) when major components of the Duke criteria (positive blood culture and vegetation) were integrated with ICD codes. CONCLUSION: Integrating EMR data can considerably improve the accuracy of ICD-only approaches in phenotyping IE, which can improve the validity of EMR-based studies and their applications, including real-time surveillance and clinical decision support.

Risk factors for surgical site infections and assessment of vancomycin powder as a preventive measure in patients undergoing first-time cranioplasty.

OBJECTIVE Craniectomy is often performed to decrease intracranial pressure following trauma and vascular injuries. The subsequent cranioplasty procedures may be complicated by surgical site infections (SSIs) due to prior trauma, foreign implants, and multiple surgeries through a common incision. Several studies have found that intrawound vancomycin powder (VP) is associated with decreased risk of SSIs after spine operations. However, no previously published study has evaluated the effectiveness of VP in cranioplasty procedures. The purpose of this study was to determine whether intrawound VP is associated with decreased risk of SSIs, to evaluate VP's safety, and to identify risk factors for SSIs after cranioplasty among patients undergoing first-time cranioplasty. METHODS The authors conducted a retrospective cohort study of adult patients undergoing first-time cranioplasty for indications other than infections from January 1, 2008, to July 31, 2014, at an academic health center. Data on demographics, possible risk factors for SSIs, and treatment with VP were collected from the patients' electronic health records. RESULTS During the study period, 258 patients underwent first-time cranioplasties, and 15 (5.8%) of these patients acquired SSIs. Ninety-two patients (35.7%) received intrawound VP (VP group) and 166 (64.3%) did not (no-VP group). Patients in the VP group and the no-VP group were similar with respect to age, sex, smoking history, body mass index, and SSI rates (VP group 6.5%, no-VP group 5.4%, p = 0.72). Patients in the VP group were less likely than those in the no-VP group to have undergone craniectomy for tumors and were more likely to have an American Society of Anesthesiologists physical status score > 2. Intrawound VP was not associated with other postoperative complications. Risk factors for SSI from the bivariable analyses were diabetes (odds ratio [OR] 3.65, 95% CI 1.07-12.44), multiple craniotomy procedures before the cranioplasty (OR 4.39, 95% CI 1.47-13.18), prior same-side craniotomy (OR 4.73, 95% CI 1.57-14.24), and prosthetic implants (OR 4.51, 95% CI 1.40-14.59). The multivariable analysis identified prior same-side craniotomy (OR 3.37, 95% CI 1.06-10.79) and prosthetic implants (OR 3.93, 95% CI 1.15-13.40) as significant risk factors for SSIs. After adjusting for potential confounders, patients with SSIs were more likely than those without SSIs to be readmitted (OR 7.28, 95% CI 2.07-25.60). CONCLUSIONS In this study, intrawound VP was not associated with a decreased risk of SSIs or with an increased risk of complications. Prior same-side craniotomy and prosthetic implants were risk factors for SSI after first-time cranioplasty.

Incidence of Extended-Spectrum ß-Lactamase (ESBL)-Producing Escherichia coli and Klebsiella Infections in the United States: A Systematic Literature Review.

BACKGROUND Despite a reported worldwide increase, the incidence of extended-spectrum ß-lactamase (ESBL) Escherichia coli and Klebsiella infections in the United States is unknown. Understanding the incidence and trends of ESBL infections will aid in directing research and prevention efforts. OBJECTIVE To perform a literature review to identify the incidence of ESBL-producing E. coli and Klebsiella infections in the United States. DESIGN Systematic literature review. METHODS MEDLINE via Ovid, CINAHL, Cochrane library, NHS Economic Evaluation Database, Web of Science, and Scopus were searched for multicenter (≥2 sites), US studies published between 2000 and 2015 that evaluated the incidence of ESBL-E. coli or ESBL-Klebsiella infections. We excluded studies that examined resistance rates alone or did not have a denominator that included uninfected patients such as patient days, device days, number of admissions, or number of discharges. Additionally, articles that were not written in English, contained duplicated data, or pertained to ESBL organisms from food, animals, or the environment were excluded. RESULTS Among 51,419 studies examined, 9 were included for review. Incidence rates differed by patient population, time, and ESBL definition and ranged from 0 infections per 100,000 patient days to 16.64 infections per 10,000 discharges and incidence rates increased over time from 1997 to 2011. Rates were slightly higher for ESBL-Klebsiella infections than for ESBL-E. coli infections. CONCLUSION The incidence of ESBL-E. coli and ESBL-Klebsiella infections in the United States has increased, with slightly higher rates of ESBL-Klebsiella infections. Appropriate estimates of ESBL infections when coupled with other mechanisms of resistance will allow for the appropriate targeting of resources toward research, drug discovery, antimicrobial stewardship, and infection prevention. Infect Control Hosp Epidemiol 2017;38:1209-1215.

Incidence and Outcomes Associated With Infections Caused by Vancomycin-Resistant Enterococci in the United States: Systematic Literature Review and Meta-Analysis.

BACKGROUND Information about the health and economic impact of infections caused by vancomycin-resistant enterococci (VRE) can inform investments in infection prevention and development of novel therapeutics. OBJECTIVE To systematically review the incidence of VRE infection in the United States and the clinical and economic outcomes. METHODS We searched various databases for US studies published from January 1, 2000, through June 8, 2015, that evaluated incidence, mortality, length of stay, discharge to a long-term care facility, readmission, recurrence, or costs attributable to VRE infections. We included multicenter studies that evaluated incidence and single-center and multicenter studies that evaluated outcomes. We kept studies that did not have a denominator or uninfected controls only if they assessed postinfection length of stay, costs, or recurrence. We performed meta-analysis to pool the mortality data. RESULTS Five studies provided incidence data and 13 studies evaluated outcomes or costs. The incidence of VRE infections increased in Atlanta and Detroit but did not increase in national samples. Compared with uninfected controls, VRE infection was associated with increased mortality (pooled odds ratio, 2.55), longer length of stay (3-4.6 days longer or 1.4 times longer), increased risk of discharge to a long-term care facility (2.8- to 6.5-fold) or readmission (2.9-fold), and higher costs ($9,949 higher or 1.6-fold more). CONCLUSIONS VRE infection is associated with large attributable burdens, including excess mortality, prolonged in-hospital stay, and increased treatment costs. Multicenter studies that use suitable controls and adjust for time at risk or confounders are needed to estimate the burden of VRE infections. Infect Control Hosp Epidemiol. 2017;38:203-215.

Costs and Mortality Associated With Multidrug-Resistant Healthcare-Associated Acinetobacter Infections.

BACKGROUND Our objective was to estimate the per-infection and cumulative mortality and cost burden of multidrug-resistant (MDR) Acinetobacter healthcare-associated infections (HAIs) in the United States using data from published studies. METHODS We identified studies that estimated the excess cost, length of stay (LOS), or mortality attributable to MDR Acinetobacter HAIs. We generated estimates of the cost per HAI using 3 methods: (1) overall cost estimates, (2) multiplying LOS estimates by a cost per inpatient-day ($4,350) from the payer perspective, and (3) multiplying LOS estimates by a cost per inpatient-day from the hospital ($2,030) perspective. We deflated our estimates for time-dependent bias using an adjustment factor derived from studies that estimated attributable LOS using both time-fixed methods and either multistate models (70.4% decrease) or matching patients with and without HAIs using the timing of infection (47.4% decrease). Finally, we used the incidence rate of MDR Acinetobacter HAIs to generate cumulative incidence, cost, and mortality associated with these infections. RESULTS Our estimates of the cost per infection were $129,917 (method 1), $72,025 (method 2), and $33,510 (method 3). The pooled relative risk of mortality was 4.51 (95% CI, 1.10-32.65), which yielded a mortality rate of 10.6% (95% CI, 2.5%-29.4%). With an incidence rate of 0.141 (95% CI, 0.136-0.161) per 1,000 patient-days at risk, we estimated an annual cumulative incidence of 12,524 (95% CI, 11,509-13,625) in the United States. CONCLUSION The estimates presented here are relevant to understanding the expenditures and lives that could be saved by preventing MDR Acinetobacter HAIs. Infect Control Hosp Epidemiol 2016;1-7.