Clinical prediction tools for identifying antimicrobial-resistant organism (ARO) carriage on hospital admissions: a systematic review.

BACKGROUND: Increasing prevalence of antimicrobial-resistant organisms (AROs) is a growing economic and healthcare challenge. Increasing utilization of electronic medical record (EMR) systems and improvements in computation and analytical techniques afford an opportunity to reduce the spread of AROs through the development of clinical prediction tools to identify ARO carriers on admission to hospital. AIM: To identify existing clinical prediction tools for meticillin-resistant Staphylococcus aureus (MRSA) and carbapenemase-producing organisms (CPOs), their predictive performance, and risk factors utilized in these tools. METHODS: The CHARMS checklist was followed. Medline, EMBASE, Cochrane SR, CRD databases (DARE, NHS EED), CINAHL and Web of Science were searched from database inception to 26th July 2021. Full-text articles were assessed independently, and quality assessment was conducted using the Prediction Model Risk of Bias Assessment Tool. FINDINGS: In total, 3809 abstracts were identified and 22 studies were included. Among these studies, risk score models were the most common prediction tool (N=16). Previous admission, recent antibiotic exposure, age and sex were the most common risk factors for ARO carriage. Prediction tools were commonly evaluated on sensitivity and specificity with ranges of 15-100% and 46-98.6%, respectively, for MRSA, and 30-81.3% and 79.8-99.9%, respectively, for CPOs. CONCLUSION: There is no gold standard ARO prediction tool. However, high-performance clinical prediction tools and identification of key risk factors for the early detection of AROs exist. Risk score models are easier to use and interpret; however, with recent improvements in machine learning techniques, highly robust models can be developed with data stored in an EMR.

Retrospective analysis of the management strategies for surgical site infection post total hip or knee arthroplasty from tertiary care centres in Edmonton, Alberta.

BACKGROUND: Surgical site infection (SSI) following hip or knee arthroplasty poses a serious health and economic burden. AIM: To evaluate SSI management strategies and outcomes to help address this problem. METHODS: A retrospective cohort study was undertaken of adults undergoing primary total hip or knee arthroplasty who were identified to have a complex SSI by infection prevention and control surveillance audit. Audits identified SSI within 90 days of arthroplasty. Patients at two tertiary referral centres in Edmonton, Alberta, Canada from 2012 to 2019 were included, and SSI cases were followed for 2 years. FINDINGS: In total, 240 SSIs were identified. Of these, 202 (84%) cases were managed with debridement with antibiotics and implant retention (DAIR), of which 71% achieved cure. The use of any topical intra-operative antibiotic in DAIR was not associated with improved outcome (odds ratio 1.68, 95% confidence interval 0.91-3.10; P=0.097). DAIR performed 31-90 days after arthroplasty had a lower chance of cure compared with DAIR performed within 30 days of arthroplasty; however, this difference was not significant (60 vs 73%; P=0.123). Initial treatment failures requiring additional surgery had a 51% cure rate. The majority (78%) of treatment failures initially managed with DAIR ultimately required two-stage revision. CONCLUSIONS: This study provides insight from a population-based perspective into the surgical management of SSI after primary total hip or knee arthroplasty in a large cohort. Additionally, SSIs that had initial management failure were followed. These data can inform future studies, such as the economic burden associated with these infections, and may be used to plan interventions to optimize SSI management.

Differences in outcomes for hospitalizations of systemic and non-systemic infections associated with vascular and cardiac grafts and devices: a population-based study.

BACKGROUND: Use of vascular and cardiac devices has expanded and is associated with a relative, though disproportionate, increase in device-associated infections. AIM: To describe the association between cardiac/vascular device infections and outcomes in those with, and without systemic infections. METHODS: We used the 2016 National Inpatient Sample and the International Classification of Diseases - 10th revision codes to identify hospitalized individuals with vascular and cardiac device infections. Linear and logistic regression models were utilized to compare outcomes of death, length of stay (LOS) and hospitalization costs between individuals with and without systemic infection. FINDINGS: There were a total of 65,110 hospitalizations associated with device infections with a mean age of 61.3 ± 15.9 years (standard deviation); 28,650 (44%) had systemic infections. Elixhauser comorbidity scores of three or greater were observed in 91.2% of individuals with systemic infections along with a higher prevalence of diabetes, renal disease and heart failure. The primary outcome of mortality was observed in 3965 individuals with an odds ratio of 3.97 (95% confidence interval (CI), 2.92-3.95) in those with systemic infections compared with those without. Mean LOS was 3.44 days longer (95% CI, 2.92-3.95) and mean cost was US$11,776 greater (95% CI, US$9826-12,727) in the systemic infection cohort. CONCLUSION: Systemic cardiac and vascular device infections were associated with increased mortality, LOS and costs. Considering the increasing use of these life-saving devices, further work is needed to identify those at risk for infectious complications, particularly systemic infection, in order to enhance preventative strategies and improve health outcomes.

Vancomycin area under the curve to minimum inhibitory concentration ratio predicting clinical outcome: a systematic review and meta-analysis with pooled sensitivity and specificity.

BACKGROUND: Vancomycin is a first-line antibiotic for methicillin-resistant Staphylococcus aureus infections or other Gram-positive infections. The area under the curve (AUC) to minimum inhibitory concentration (MIC) ratio is proposed as a therapeutic drug-monitoring parameter. How well clinical efficacy is predicted by this measure has not been established. OBJECTIVE: Determine the test performance characteristics (TPC) of AUC:MIC of vancomycin for prediction of positive outcome. DATA SOURCES: PubMed and Ovid Medline (1946 to 2018) and EMBASE (1974 to 2018). Study Eligibility Criteria and Participants: Studies of patients treated with vancomycin for any type of infection in peer reviewed publications. All patient populations were included. INTERVENTIONS: Vancomycin AUC:MIC or AUC was related to patient clinical outcome. METHODS: Searches of medical databases using relevant terms were performed. Screening, study reviewing, data extracting and assessing data quality was performed independently by two reviewers. Studies were stratified by type of primary outcome for calculation of pooled sensitivity, specificity and construction of hierarchical summary receiver operating characteristic (HSROC) curves. RESULTS: Nineteen studies including 1699 patients were meta-analysed. Pooled sensitivity and specificity were 0.77 (95% CI 0.67-0.84) and 0.62 (95% CI 0.53-0.71) respectively for the seven studies with primary outcome of mortality and 0.65 (95% CI 0.53-0.75), 0.58 (95% CI 0.48-0.67) for studies with composite or clinical cure outcome (n = 12). HSROC curves suggested considerable heterogeneity. An additional 11 studies were described but could not be included for meta-analysis because data were not available. The majority of these studies (9/11) failed to demonstrate a relationship between AUC:MIC and positive clinical outcome. CONCLUSIONS: Vancomycin AUC:MIC performance was modest and inconsistent. Analysis was limited by studies without sufficient data; therefore, meta-analytic results may overestimate TPC values. Given this, as well as the lack of standardization of methods, widespread adoption of AUC:MIC as the preferred vancomycin monitoring parameter may be premature.

Clinical outcomes in patients admitted to a hospitalist service exposed to an antimicrobial stewardship program - a retrospective matched cohort study.

Background: Given global issues with antimicrobial resistance and a need to optimize antimicrobial usage, antimicrobial stewardship (AS) programs are becoming a necessary component of hospitals and are increasingly mandated worldwide. It is important to evaluate these programs with respect to relevant clinical outcomes. Methods: An AS program with a prospective audit and feedback service (PAF) of antimicrobial usage was initiated May 11, 2015 at our tertiary care center, for patients admitted under the hospitalist service. We conducted a retrospective matched cohort study. Patients assessed during the first year of this PAF were considered to be the exposed cohort and were compared to unexposed controls matched on gender, age and infectious diagnosis selected from patients who had been admitted under the hospitalist service prior to initiation of the PAF. Descriptive analysis was completed and a multivariate conditional logistic regression was performed to analyze differences between the exposed and control groups in terms of a composite endpoint of 30 day mortality, 30 day post hospital discharge mortality and hospital re-admission. Results: A total of 348 patients were assessed and received PAF suggestions during the first year were compared to 827 matched control patients who did not receive PAF suggestions. Of 707 PAF suggestions made, the most common was to stop an antimicrobial (23%). A significantly lower (20.7% vs 28.8%, p = 0.008) composite endpoint was found in the group exposed to the PAF (OR 0.71 95%CI 0.52-0.97). This difference persisted when only patients with PAF suggestions that were completely or partially accepted were considered (18.6% vs 28.5%, p = 0.001) but was no longer significant when patients who had their ASP suggestions declined were analyzed (30.2% vs 26.7%, p = 0.610). Conclusions: In this retrospective cohort study, patient admissions in which PAF recommendations were accepted had better clinical outcomes than matched historical controls managed in the absence of this AS service.

Rationale and development of a business case for antimicrobial stewardship programs in acute care hospital settings.

Background: Antimicrobial stewardship programs (ASPs) have been shown to reduce inappropriate antimicrobial use and its consequences. However, these programs lack legislative requirements in many places and it can be difficult to determine what human resources are required for these programs and how to create a business case to present to hospital administrators for program funding. The objectives of the current paper were to review legislative requirements and outline human resource requirements for ASPs, and to create a base business case for ASPs. Methods: A working group of antimicrobial stewardship experts from across Canada met to discuss the necessary components for creation of a business case for antimicrobial stewardship. A narrative review of the literature of the regulatory requirements and human resource recommendations for ASPs was conducted. Informed by the review and using a consensus decision-making process, the expert working group developed human resource recommendations based on a 1000 bed acute care health care facility in Canada. A spreadsheet based business case model for ASPs was also created. Results: Legislative and /or regulatory requirements for ASPs were found in 2 countries and one state jurisdiction. The literature review and consensus development process recommended the following minimum human resources complement: 1 physician, 3 pharmacists, 0.5 program administrative and coordination support, and 0.4 data analyst support as full time equivalents (FTEs) per 1000 acute care beds. Necessary components for the business case model, including the human resource requirements, were determined to create a spreadsheet based model. Conclusions: There is evidence to support the negative outcomes of inappropriate antimicrobial use as well as the benefits of ASPs. Legislative and /or regulatory requirements for ASPs are not common. The available evidence for human resource recommendations for ASPs using a narrative review process was examined and a base business case modelling scenario was created. As regulatory requirements for ASPs increase, it will be necessary to create accurate business cases for ASPs in order to obtain the necessary funding to render these programs successful.

Haptic Processing of Facial Expressions of Emotion in 2D Raised-Line Drawings.

Participants haptically (vs. visually) classified universal facial expressions of emotion (FEEs) depicted in simple 2D raised-line displays. Experiments 1 and 2 established that haptic classification was well above chance; face-inversion effects further indicated that the upright orientation was privileged. Experiment 2 added a third condition in which the normal configuration of the upright features was spatially scrambled. Results confirmed that configural processing played a critical role, since upright FEEs were classified more accurately and confidently than either scrambled or inverted FEEs, which did not differ. Because accuracy in both scrambled and inverted conditions was above chance, feature processing also played a role, as confirmed by commonalities across confusions for upright, inverted, and scrambled faces. Experiment 3 required participants to visually and haptically assign emotional valence (positive/negative) and magnitude to upright and inverted 2-D FEE displays. While emotional magnitude could be assigned using either modality, haptic presentation led to more variable valence judgments. We also documented a new face-inversion effect for emotional valence visually, but not haptically. These results suggest emotions can be interpreted from 2-D displays presented haptically as well as visually; however, emotional impact is judged more reliably by vision than by touch. Potential applications of this work are also considered.