Individualized Antibiotic Plans as a Quality Improvement Initiative to Reduce Carbapenem Use for Hematopoietic Cell Transplant Patients at a Freestanding Pediatric Hospital.

BACKGROUND: Providers must balance effective empiric therapy against toxicity risks and collateral damage when selecting antibiotic therapy for patients receiving hematopoietic cell transplant (HCT). Antimicrobial stewardship interventions during HCT are often challenging due to concern for undertreating potential infections. METHODS: In an effort to decrease unnecessary carbapenem exposure for patients undergoing HCT at our pediatric center, we implemented individualized antibiotic plans (IAPs) to provide recommendations for preengraftment neutropenia prophylaxis, empiric treatment of febrile neutropenia, and empiric treatment for hemodynamic instability. We compared monthly antibiotic days of therapy (DOT) adjusted per 1000 patient-days for carbapenems, antipseudomonal cephalosporins, and all antibiotics during two 3-year periods immediately before and after the implementation of IAPs to measure the impact of IAP on prescribing behavior. Bloodstream infection (BSIs) and Clostridioides difficile (CD) positivity test rates were also compared between cohorts. Last, providers were surveyed to assess their experience of using IAPs in antibiotic decision making. RESULTS: Overall antibiotic use decreased after the implementation of IAPs (monthly reduction of 19.6 DOT/1000 patient-days; P = .004), with carbapenems showing a continuing decline after IAP implementation. BSI and CD positivity rates were unchanged. More than 90% of providers found IAPs to be either extremely or very valuable for their practice. CONCLUSIONS: Implementation of IAPs in this high-risk HCT population led to reduction in overall antibiotic use without increase in rate of BSI or CD test positivity. The program was well received by providers.

Identifying and Mitigating Disparities in Central Line-Associated Bloodstream Infections in Minoritized Racial, Ethnic, and Language Groups.

Importance: Although inequitable care due to racism and bias is well documented in health care, the impact on health care-associated infections is less understood. Objective: To determine whether disparities in first central catheter-associated bloodstream infection (CLABSI) rates existed for pediatric patients of minoritized racial, ethnic, and language groups and to evaluate the outcomes associated with quality improvement initiatives for addressing these disparities. Design, Setting, and Participants: This cohort study retrospectively examined outcomes of 8269 hospitalized patients with central catheters from October 1, 2012, to September 30, 2019, at a freestanding quaternary care children's hospital. Subsequent quality improvement interventions and follow-up were studied, excluding catheter days occurring after the outcome and episodes with catheters of indeterminate age through September 2022. Exposures: Patient self-reported (or parent/guardian-reported) race, ethnicity, and language for care as collected for hospital demographic purposes. Main Outcomes and Measures: Central catheter-associated bloodstream infection events identified by infection prevention surveillance according to National Healthcare Safety Network criteria were reported as events per 1000 central catheter days. Cox proportional hazards regression was used to analyze patient and central catheter characteristics, and interrupted time series was used to analyze quality improvement outcomes. Results: Unadjusted infection rates were higher for Black patients (2.8 per 1000 central catheter days) and patients who spoke a language other than English (LOE; 2.1 per 1000 central catheter days) compared with the overall population (1.5 per 1000 central catheter days). Proportional hazard regression included 225 674 catheter days with 316 infections and represented 8269 patients. A total of 282 patients (3.4%) experienced a CLABSI (mean [IQR] age, 1.34 [0.07-8.83] years; female, 122 [43.3%]; male, 160 [56.7%]; English-speaking, 236 [83.7%]; LOE, 46 [16.3%]; American Indian or Alaska Native, 3 [1.1%]; Asian, 14 [5.0%]; Black, 26 [9.2%]; Hispanic, 61 [21.6%]; Native Hawaiian or Other Pacific Islander, 4 [1.4%]; White, 139 [49.3%]; ≥2 races, 14 [5.0%]; unknown race and ethnicity or refused to answer, 15 [5.3%]). In the adjusted model, a higher hazard ratio (HR) was observed for Black patients (adjusted HR, 1.8; 95% CI, 1.2-2.6; P = .002) and patients who spoke an LOE (adjusted HR, 1.6; 95% CI, 1.1-2.3; P = .01). Following quality improvement interventions, infection rates in both subgroups showed statistically significant level changes (Black patients: -1.77; 95% CI, -3.39 to -0.15; patients speaking an LOE: -1.25; 95% CI, -2.23 to -0.27). Conclusions and Relevance: The study's findings show disparities in CLABSI rates for Black patients and patients who speak an LOE that persisted after adjusting for known risk factors, suggesting that systemic racism and bias may play a role in inequitable hospital care for hospital-acquired infections. Stratifying outcomes to assess for disparities prior to quality improvement efforts may inform targeted interventions to improve equity.

Can we automate spine fusion surgical site infection data capture?

PURPOSE: Spine fusion surgical site infection (SSI) rate is reported to national quality databases and used as a benchmark for orthopedic departments and hospital systems. However, accurate data require resource-heavy administrative review and even this has shown to vary. We aimed to create a passive electronic medical record (EMR) algorithm to automatically capture spine fusion SSI and compared its accuracy against the administrative chart review and self-reported morbidity and mortality (M&M) rates. METHODS: We retrospectively reviewed a single institution's spine fusion records for 7 years for all 90-day post-operative SSIs. We used Centers for Disease Control and Prevention (CDC) SSI definition coupled with intention to treat as an infection by orthopedics/infectious disease service as the gold standard. We compared our gold standard to administrative hand-checked SSI data, anonymously reported departmental M&M, and a passive EMR algorithm (ICD-9 or -10 post-operative SSI diagnosis code entered, or all four of: positive culture, antibiotic prescription between 3-90 days post-op, re-operation/re-admission, and a qualifying diagnosis). RESULTS: Nine hundred and fourteen spine fusions were included, with a 2.8% SSI rate (0.9% superficial and 2.0% deep). Passive EMR algorithm was the most sensitive at 89% (vs 76% administrative review, 73% M&M); all were highly specific at 99-100%. M&M was 100% positively predictive, administrative review 95%, and EMR 79%. CONCLUSION: Our passive EMR algorithm was more sensitive to pediatric spine fusion 90-day SSI than self-reported M&M and hand-checked administrative chart review. Although EMR may over-report, it can be used by others to narrow the initial sample for review, reduce resource burden involved with administrative spine SSI review, and provide a quality check for M&M self-reporting. LEVEL OF EVIDENCE: III.

Flushing an Offensive Term for Vancomycin Infusion Reaction From the Electronic Medical Record.

BACKGROUND: The medical establishment continues to be complicit in the degradation of native peoples of the United States through the use of the racist phrase "red man syndrome" (RMS) to describe the histamine-release syndrome that accompanies vancomycin infusion. METHODS: Five months after the transition from 1 electronic health record to another at our freestanding children's hospital, our antimicrobial stewardship team reviewed all active allergy records to identify and then replace use of RMS terminology with preferred alternative "vancomycin flushing syndrome." In partnership with institutional stakeholders, we also launched an educational campaign and instituted in the electronic health record an autocorrect functionality to prevent new RMS entries. RESULTS: We identified allergy records for 21 034 individual patients. Vancomycin was an allergen for 445 (2.1%) patients, and RMS-related terminology appeared in 274 (61.6%) of these records; we replaced all RMS instances with the vancomycin flushing syndrome term. During the 3-month period after the intervention, we identified allergy records for 8648 additional patients, with vancomycin as allergen in 65 (0.7%) and with RMS terminology identified and replaced in 29 (44.6%). In addition to the lower rate of RMS among allergy records after the intervention, we detected 3 instances of alternative terminology use. CONCLUSIONS: Implementing an institutional-level change in terminology, even for racist language, requires education, reinforcement, and continued surveillance. To effectively replace this term, we need the support of national stakeholders to remove this language from our medical education systems, our textbooks, and our clinical lexicon.

Antibiotic stewardship from a decision-making, behavioral economics, and incentive design perspective.

Antibiotic-resistant infections cause over 20 thousand deaths and $20 billion annually in the United States. Antibiotic prescribing decision making can be described as a "tragedy of the commons" behavioral economics problem, for which individual best interests affecting human decision-making lead to suboptimal societal antibiotic overuse. In 2015, the U.S. federal government announced a $1.2 billion National Action Plan to combat resistance and reduce antibiotic use by 20% in inpatient settings and 50% in outpatient settings by 2020. We develop and apply a behavioral economics model based on game theory and "tragedy of the commons" concepts to help illustrate why rational individuals may not practice ideal stewardship and how to potentially structure three specific alternate approaches to accomplish these objectives (collective cooperative management, usage taxes, resistance penalties), based on Ostrom's economic governance principles. Importantly, while each approach can effectively incentivize ideal stewardship, the latter two do so with 10-30% lower utility to all providers. Encouraging local or state-level self-managed cooperative stewardship programs thus is preferred to national taxes and penalties, in contrast with current trends and with similar implications in other countries.

Validation of an Electronic Surveillance Algorithm to Identify Patients With Post-Operative Surgical Site Infections Using National Surgical Quality Improvement Program Pediatric Data.

BACKGROUND: Surgical site infections (SSIs) are common, but data related to these infections maybe difficult to capture. We developed an electronic surveillance algorithm to identify patients with SSIs. Our objective was to validate our algorithm by comparing it with our institutional National Surgical Quality Improvement Program Pediatric (NSQIP Peds) data. METHODS: We applied our algorithm to our institutional NSQIP Peds 2015-2017 cohort. The algorithm consisted of the presence of a diagnosis code for post-operative infection or the presence of 4 criteria: diagnosis code for infection, antibiotic administration, positive culture, and readmission/surgery related to infection. We compared the algorithm's SSI rate to the NSQIP Peds identified SSI. Algorithm performance was assessed using sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and Cohen's kappa. The charts of discordant patients were reviewed to understand limitations of the algorithm. RESULTS: Of 3879 patients included, 2.5% had SSIs by NSQIP Peds definition and 1.9% had SSIs by our algorithm. Our algorithm achieved a sensitivity of 44%, specificity of 99%, NPV of 99%, PPV of 59%, and Cohen's kappa of 0.5. Of the 54 false negatives, 37% were diagnosed/treated as outpatients, 31% had tracheitis, and 17% developed SSIs during their post-operative admission. Of the 30 false positives, 33% had an infection at index surgery and 33% had SSIs related to other surgeries/procedures. CONCLUSIONS: Our algorithm achieved high specificity and NPV compared with NSQIP Peds reported SSIs and may be useful when identifying SSIs in patient populations that are not actively monitored for SSIs.