Overcoming Barriers to Autologous Stem Cell Transplantation in Multiple Myeloma: Recommendations from a Multidisciplinary Roundtable Discussion.

Autologous stem cell transplantation (ASCT) is a standard of care treatment for patients with multiple myeloma (MM). However, only 20% to 30% of patients with MM for whom the procedure is indicated undergo ASCT. Barriers to ASCT may be informational, financial, logistic, or cultural and may affect patients and treating oncologists. Available and accessible accurate ASCT-related information is essential to overcome these barriers. Such resources can be created by blood and marrow transplantation societies and patient advocacy groups, ideally in collaboration with MM specialists at transplant centers. An umbrella office at the society level is also recommended to connect oncologists, advocacy groups, and transplantation specialists; provide informational resources to patients; and conduct research into region- and population-specific barriers to ASCT.

Comparing bloodstream infection rates: the effect of indicator specifications in the evaluation of processes and indicators in infection control (EPIC) study.

OBJECTIVE: Bloodstream infection (BSI) rates are used as comparative clinical performance indicators; however, variations in definitions and data-collection approaches make it difficult to compare and interpret rates. To determine the extent to which variation in indicator specifications affected infection rates and hospital performance rankings, we compared absolute rates and relative rankings of hospitals across 5 BSI indicators. DESIGN: Multicenter observational study. BSI rate specifications varied by data source (clinical data, administrative data, or both), scope (hospital wide or intensive care unit specific), and inclusion/exclusion criteria. As appropriate, hospital-specific infection rates and rankings were calculated by processing data from each site according to 2-5 different specifications. SETTING: A total of 28 hospitals participating in the EPIC study. PARTICIPANTS: Hospitals submitted deidentified information about all patients with BSIs from January through September 1999. RESULTS: Median BSI rates for 2 indicators based on intensive care unit surveillance data ranged from 2.23 to 2.91 BSIs per 1000 central-line days. In contrast, median rates for indicators based on administrative data varied from 0.046 to 7.03 BSIs per 100 patients. Hospital-specific rates and rankings varied substantially as different specifications were applied; the rates of 8 of 10 hospitals were both greater than and less than the mean. Correlations of hospital rankings among indicator pairs were generally low (rs=0-0.45), except when both indicators were based on intensive care unit surveillance (rs = 0.83). CONCLUSIONS: Although BSI rates seem to be a logical indicator of clinical performance, the use of various indicator specifications can produce remarkably different judgments of absolute and relative performance for a given hospital. Recent national initiatives continue to mix methods for specifying BSI rates; this practice is likely to limit the usefulness of such information for comparing and improving performance.

Use of antimicrobial prophylaxis for major surgery: baseline results from the National Surgical Infection Prevention Project.

HYPOTHESIS: Surgical site infections (SSIs) are a major contributor to patient injury, mortality, and health care costs. Despite evidence of effectiveness of antimicrobials to prevent SSIs, previous studies have demonstrated inappropriate timing, selection, and excess duration of administration of antimicrobial prophylaxis. We herein describe the use of antimicrobial prophylaxis for Medicare patients undergoing major surgery. DESIGN: National retrospective cohort study with medical record review. SETTING: Two thousand nine hundred sixty-five acute-care US hospitals. PATIENTS: A systematic random sample of 34,133 Medicare inpatients undergoing coronary artery bypass grafting; other open-chest cardiac surgery (excluding transplantation); vascular surgery, including aneurysm repair, thromboendarterectomy, and vein bypass operations; general abdominal colorectal surgery; hip and knee total joint arthroplasty (excluding revision surgery); and abdominal and vaginal hysterectomy from January 1 through November 30, 2001. MAIN OUTCOME MEASURES: The proportion of patients who had parenteral antimicrobial prophylaxis initiated within 1 hour before the surgical incision; the proportion of patients who were given a prophylactic antimicrobial agent that was consistent with currently published guidelines; and the proportion of patients whose antimicrobial prophylaxis was discontinued within 24 hours after surgery. RESULTS: An antimicrobial dose was administered to 55.7% (95% confidence interval [CI], 54.8%-56.6%) of patients within 1 hour before incision. Antimicrobial agents consistent with published guidelines were administered to 92.6% (95% CI, 92.3%-92.8%) of the patients. Antimicrobial prophylaxis was discontinued within 24 hours of surgery end time for only 40.7% (95% CI, 40.2%-41.2%) of patients. CONCLUSION: Substantial opportunities exist to improve the use of prophylactic antimicrobials for patients undergoing major surgery.

The use of economic modeling to determine the hospital costs associated with nosocomial infections.

Hospital-associated infection is well recognized as a patient safety concern requiring preventive interventions. However, hospitals are closely monitoring expenditures and need accurate estimates of potential cost savings from such prevention programs. We used a retrospective cohort design and economic modeling to determine the excess cost from the hospital perspective for hospital-associated infection in a random sample of adult medical patients. Study patients were classified as being not infected (n=139), having suspected infection (n=8), or having confirmed infection (n=17). Severity of illness and intensive unit care use were both independently associated with increased cost. After controlling for these confounding effects, we found an excess cost of $6767 for suspected infection and $15,275 for confirmed hospital-acquired infection. The economic model explained 56% of the total variability in cost among patients. Hospitals can use these data when evaluating potential cost savings from effective infection-control measures.

Bioterrorism web site resources for infectious disease clinicians and epidemiologists.

Finding bioterrorism-related information on the World Wide Web can be laborious. We hope to help readers find such information more easily by summarizing essential information in a consistent framework. A panel of 7 Centers for Disease Control and Prevention reviewers identified Web sites and evaluated them for sponsorship, mission, content usefulness, online ease of use, and adherence to commonly accepted quality criteria. Of >100 potential sites identified, 81 were chosen for target content of interest, and 43 were selected for inclusion. The results were classified into general purpose/portal sites; biological agent information; laboratory, infection control, epidemiology, and mental health information; and emergency contact sources, news and updates, event preparedness resources, information for first-responder settings, clinical and public education materials, and research resources. Agents covered included anthrax, smallpox, plague, botulism, tularemia, and viral hemorrhagic fever.

Preventing central venous catheter-associated primary bloodstream infections: characteristics of practices among hospitals participating in the Evaluation of Processes and Indicators in Infection Control (EPIC) study.

OBJECTIVES: To describe the conceptual framework and methodology of the Evaluation of Processes and Indicators in Infection Control (EPIC) study and present results of CVC insertion characteristics and organizational practices for preventing BSIs. The goal of the EPIC study was to evaluate relationships among processes of care, organizational characteristics, and the outcome of BSI. DESIGN: This was a multicenter prospective observational study of variation in hospital practices related to preventing CVC-associated BSIs. Process of care information (eg, barrier use during insertions and experience of the inserting practitioner) was collected for a random sample of approximately 5 CVC insertions per month per hospital during November 1998 to December 1999. Organization demographic and practice information (eg, surveillance activities and staff and ICU nurse staffing levels) was also collected. SETTING: Medical, surgical, or medical-surgical ICUs from 55 hospitals (41 U.S. and 14 international sites). PARTICIPANTS: Process information was obtained for 3,320 CVC insertions with an average of 58.2 (+/- 16.1) insertions per hospital. Fifty-four hospitals provided policy and practice information. RESULTS: Staff spent an average of 13 hours per week in study ICU surveillance. Most patients received nontunneled, multiple lumen CVCs, of which fewer than 25% were coated with antimicrobial material. Regarding barriers, most clinicians wore masks (81.5%) and gowns (76.8%); 58.1% used large drapes. Few hospitals (18.1%) used an intravenous team to manage ICU CVCs. CONCLUSIONS: Substantial variation exists in CVC insertion practice and BSI prevention activities. Understanding which practices have the greatest impact on BSI rates can help hospitals better target improvement interventions.

Epidemiology of vancomycin-resistant Enterococcus faecium under a selective isolation policy at an urban county hospital.

BACKGROUND: We report our experience in a county hospital with the use of selective contact isolation for patients with vancomycin-resistant Enterococcus faecium (VREF). About 12% of patients with VREF are isolated for reasons such as draining wounds and uncontrolled diarrhea. METHODS: Passive surveillance identified all inpatients (181) from 1995 to 1999 with cultures positive for VREF. Data were collected via electronic databases and from prospectively maintained infection control records. Isolates were typed with use of pulsed-field gel electrophoresis. RESULTS: Nearly all patients (175/181) with VREF had been admitted at least 48 hours or had a history of previous hospitalization. Most patients (69%) had urine cultures positive for VREF without blood cultures positive for the organism. Only 12 of 127 (9.%) patients with complete data had VREF infection on the basis of receiving treatment and/or having more than 1 blood culture positive for VREF. After VREF became endemic, statistically significant increased prevalence was not detected via surveillance of clinical cultures nor sequential point-prevalence studies. Two major genotypes carrying vanB resistance genes were identified and persisted throughout the period studied. VREF persisted in individual patients up to 46 months. CONCLUSIONS: The number of VREF infections in this facility has been low, despite appreciable colonization, for an extended period during which selective isolation was used.

Factors associated with antimicrobial use in nursing homes: a multilevel model.

OBJECTIVES: To describe antimicrobial prescribing patterns in nursing homes. DESIGN: Retrospective, observational study. SETTING: Total of 73 nursing homes in four U.S. states; study period was from September 1, 2001, through February 28, 2002. PARTICIPANTS: Four thousand seven hundred eighty nursing home residents. MEASUREMENTS: Number and type of antimicrobials, indication for their use, and resident and facility factors associated with antimicrobial use in nursing homes. RESULTS: Of 4,780 residents, 2,017 (42%) received one or more antibiotic courses. Overall, residents received a mean of 4.8 courses/1,000 resident-days (mean facility range 0.4-23.5). In multivariable analysis, higher probability of nursing home discharge and of being categorized in the rehabilitation, extensive services, special care, or clinically complex Resource Utilization Groups were associated with higher rates of antimicrobial usage. Three drug classes accounted for nearly 60% of antimicrobial courses-fluoroquinolones (38%), first-generation cephalosporins (11%), and macrolides (10%). The most common conditions for which antimicrobials were prescribed were respiratory tract (33%) and urinary tract (32%) infections. CONCLUSION: Antibiotic use is variable in nursing homes. Targeting educational and other antimicrobial use interventions to the treatment of certain clinical diagnoses and conditions may be an appropriate strategy for optimizing antimicrobial use in this setting.