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Real-world effectiveness of infection prevention interventions for reducing procedure-related cardiac device infections: Insights from the veterans affairs clinical assessment reporting and tracking program
- Archana Asundi, Maggie Stanislawski, Payal Mehta, Anna E. Baron, Hillary J. Mull, P. Michael Ho, Peter J. Zimetbaum, Kalpana Gupta, Westyn Branch-Elliman
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- Journal:
- Infection Control & Hospital Epidemiology / Volume 40 / Issue 8 / August 2019
- Published online by Cambridge University Press:
- 04 June 2019, pp. 855-862
- Print publication:
- August 2019
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Objective:
To measure the association between receipt of specific infection prevention interventions and procedure-related cardiac implantable electronic device (CIED) infections.
Design:Retrospective cohort with manually reviewed infection status.
Setting:Setting: National, multicenter Veterans Health Administration (VA) cohort.
Participants:Sampling of procedures entered into the VA Clinical Assessment Reporting and Tracking-Electrophysiology (CART-EP) database from fiscal years 2008 through 2015.
Methods:A sample of procedures entered into the CART-EP database underwent manual review for occurrence of CIED infection and other clinical/procedural variables. The primary outcome was 6-month incidence of CIED infection. Measures of association were calculated using multivariable generalized estimating equations logistic regression.
Results:We identified 101 procedure-related CIED infections among 2,098 procedures (4.8% of reviewed sample). Factors associated with increased odds of infections included (1) wound complications (adjusted odds ratio [aOR], 8.74; 95% confidence interval [CI], 3.16–24.20), (2) revisions including generator changes (aOR, 2.4; 95% CI, 1.59–3.63), (3) an elevated international normalized ratio (INR) >1.5 (aOR, 1.56; 95% CI, 1.12–2.18), and (4) methicillin-resistant Staphylococcus colonization (aOR, 9.56; 95% CI, 1.55–27.77). Clinically effective prevention interventions included preprocedural skin cleaning with chlorhexidine versus other topical agents (aOR, 0.41; 95% CI, 0.22–0.76) and receipt of β-lactam antimicrobial prophylaxis versus vancomycin (aOR, 0.60; 95% CI, 0.37–0.96). The use of mesh pockets and continuation of antimicrobial prophylaxis after skin closure were not associated with reduced infection risk.
Conclusions:These findings regarding the real-world clinical effectiveness of different prevention strategies can be applied to the development of evidence-based protocols and infection prevention guidelines specific to the electrophysiology laboratory.
Prolonged antimicrobial prophylaxis following cardiac device procedures increases preventable harm: insights from the VA CART program
- Archana Asundi, Maggie Stanislawski, Payal Mehta, Anna E. Barón, Howard Gold, Hillary Mull, P. Michael Ho, Kalpana Gupta, Westyn Branch-Elliman
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- Journal:
- Infection Control & Hospital Epidemiology / Volume 39 / Issue 9 / September 2018
- Published online by Cambridge University Press:
- 18 September 2018, pp. 1030-1036
- Print publication:
- September 2018
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Background
The rate of cardiovascular implantable electronic device (CIED) infection is increasing coincident with an increase in the number of device procedures. Preprocedural antimicrobial prophylaxis reduces CIED infections; however, there is no evidence that prolonged postprocedural antimicrobials additionally reduce risk. Thus, we sought to quantify the harms associated with this approach.
ObjectiveTo measure the association between Clostridium difficile infection (CDI), acute kidney injury (AKI) and receipt of prolonged postprocedural antimicrobials.
MethodsCIED procedures entered into the VA Clinical Assessment Reporting and Tracking Electrophysiology (CART-EP) database during fiscal years 2008–2016 were included. The primary outcome was 90-day incidence of CDI and the secondary outcome was the 7-day incidence of AKI. The primary exposure measure was duration of postprocedural antimicrobial therapy. Associations were measured using Cox-proportional hazards and binomial regression.
ResultsProlonged postprocedural antimicrobial therapy was identified following 3,331 of 6,497 CIED procedures (51.3%), and the median duration of prophylaxis was 5 days. Prolonged postprocedural antimicrobial use was associated with increased risk of CDI (hazard ratio [HR], 2.90; 95% confidence interval [CI], 1.54–5.46). Of the 27 patients who developed CDI, 11 subsequently died. Postprocedural antimicrobial use with ≥2 antimicrobials was associated with an increased risk of AKI (OR, 4.16; 95% CI, 2.50–6.90). The impact was particularly significant when one of the dual agents prescribed was vancomycin (adjusted OR, 8.41; 95% CI, 5.53–12.79).
ConclusionsProlonged antimicrobial prophylaxis following CIED procedures increases preventable harm; this practice should be discouraged in procedural settings such as the cardiac electrophysiology laboratory.
Probability of major depression diagnostic classification using semi-structured versus fully structured diagnostic interviews
- Brooke Levis, Andrea Benedetti, Kira E. Riehm, Nazanin Saadat, Alexander W. Levis, Marleine Azar, Danielle B. Rice, Matthew J. Chiovitti, Tatiana A. Sanchez, Pim Cuijpers, Simon Gilbody, John P. A. Ioannidis, Lorie A. Kloda, Dean McMillan, Scott B. Patten, Ian Shrier, Russell J. Steele, Roy C. Ziegelstein, Dickens H. Akena, Bruce Arroll, Liat Ayalon, Hamid R. Baradaran, Murray Baron, Anna Beraldi, Charles H. Bombardier, Peter Butterworth, Gregory Carter, Marcos H. Chagas, Juliana C. N. Chan, Rushina Cholera, Neerja Chowdhary, Kerrie Clover, Yeates Conwell, Janneke M. de Man-van Ginkel, Jaime Delgadillo, Jesse R. Fann, Felix H. Fischer, Benjamin Fischler, Daniel Fung, Bizu Gelaye, Felicity Goodyear-Smith, Catherine G. Greeno, Brian J. Hall, John Hambridge, Patricia A. Harrison, Ulrich Hegerl, Leanne Hides, Stevan E. Hobfoll, Marie Hudson, Thomas Hyphantis, Masatoshi Inagaki, Khalida Ismail, Nathalie Jetté, Mohammad E. Khamseh, Kim M. Kiely, Femke Lamers, Shen-Ing Liu, Manote Lotrakul, Sonia R. Loureiro, Bernd Löwe, Laura Marsh, Anthony McGuire, Sherina Mohd Sidik, Tiago N. Munhoz, Kumiko Muramatsu, Flávia L. Osório, Vikram Patel, Brian W. Pence, Philippe Persoons, Angelo Picardi, Alasdair G. Rooney, Iná S. Santos, Juwita Shaaban, Abbey Sidebottom, Adam Simning, Lesley Stafford, Sharon Sung, Pei Lin Lynnette Tan, Alyna Turner, Christina M. van der Feltz-Cornelis, Henk C. van Weert, Paul A. Vöhringer, Jennifer White, Mary A. Whooley, Kirsty Winkley, Mitsuhiko Yamada, Yuying Zhang, Brett D. Thombs
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- Journal:
- The British Journal of Psychiatry / Volume 212 / Issue 6 / June 2018
- Published online by Cambridge University Press:
- 02 May 2018, pp. 377-385
- Print publication:
- June 2018
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Background
Different diagnostic interviews are used as reference standards for major depression classification in research. Semi-structured interviews involve clinical judgement, whereas fully structured interviews are completely scripted. The Mini International Neuropsychiatric Interview (MINI), a brief fully structured interview, is also sometimes used. It is not known whether interview method is associated with probability of major depression classification.
AimsTo evaluate the association between interview method and odds of major depression classification, controlling for depressive symptom scores and participant characteristics.
MethodData collected for an individual participant data meta-analysis of Patient Health Questionnaire-9 (PHQ-9) diagnostic accuracy were analysed and binomial generalised linear mixed models were fit.
ResultsA total of 17 158 participants (2287 with major depression) from 57 primary studies were analysed. Among fully structured interviews, odds of major depression were higher for the MINI compared with the Composite International Diagnostic Interview (CIDI) (odds ratio (OR) = 2.10; 95% CI = 1.15–3.87). Compared with semi-structured interviews, fully structured interviews (MINI excluded) were non-significantly more likely to classify participants with low-level depressive symptoms (PHQ-9 scores ≤6) as having major depression (OR = 3.13; 95% CI = 0.98–10.00), similarly likely for moderate-level symptoms (PHQ-9 scores 7–15) (OR = 0.96; 95% CI = 0.56–1.66) and significantly less likely for high-level symptoms (PHQ-9 scores ≥16) (OR = 0.50; 95% CI = 0.26–0.97).
ConclusionsThe MINI may identify more people as depressed than the CIDI, and semi-structured and fully structured interviews may not be interchangeable methods, but these results should be replicated.
Declaration of interestDrs Jetté and Patten declare that they received a grant, outside the submitted work, from the Hotchkiss Brain Institute, which was jointly funded by the Institute and Pfizer. Pfizer was the original sponsor of the development of the PHQ-9, which is now in the public domain. Dr Chan is a steering committee member or consultant of Astra Zeneca, Bayer, Lilly, MSD and Pfizer. She has received sponsorships and honorarium for giving lectures and providing consultancy and her affiliated institution has received research grants from these companies. Dr Hegerl declares that within the past 3 years, he was an advisory board member for Lundbeck, Servier and Otsuka Pharma; a consultant for Bayer Pharma; and a speaker for Medice Arzneimittel, Novartis, and Roche Pharma, all outside the submitted work. Dr Inagaki declares that he has received grants from Novartis Pharma, lecture fees from Pfizer, Mochida, Shionogi, Sumitomo Dainippon Pharma, Daiichi-Sankyo, Meiji Seika and Takeda, and royalties from Nippon Hyoron Sha, Nanzando, Seiwa Shoten, Igaku-shoin and Technomics, all outside of the submitted work. Dr Yamada reports personal fees from Meiji Seika Pharma Co., Ltd., MSD K.K., Asahi Kasei Pharma Corporation, Seishin Shobo, Seiwa Shoten Co., Ltd., Igaku-shoin Ltd., Chugai Igakusha and Sentan Igakusha, all outside the submitted work. All other authors declare no competing interests. No funder had any role in the design and conduct of the study; collection, management, analysis and interpretation of the data; preparation, review or approval of the manuscript; and decision to submit the manuscript for publication.
Cardiac Electrophysiology Laboratories: A Potential Target for Antimicrobial Stewardship and Quality Improvement?
- Westyn Branch-Elliman, Maggie Stanislawski, Judith Strymish, Anna E. Barón, Kalpana Gupta, Paul D. Varosy, Howard S. Gold, P. Michael Ho
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- Journal:
- Infection Control & Hospital Epidemiology / Volume 37 / Issue 9 / September 2016
- Published online by Cambridge University Press:
- 20 June 2016, pp. 1005-1011
- Print publication:
- September 2016
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BACKGROUND
Infections following cardiovascular implantable electronic device (CIED) procedures, including pacemaker and implantable cardioverter–defibrillators, are devastating and costly. Preimplantation prophylactic antimicrobials are effective for reducing postprocedural infections. However, routine postprocedural antimicrobials are not associated with improved outcomes, and they may be harmful. Thus, we sought to characterize antimicrobial use patterns following CIED procedures.
DESIGNAll patients who underwent CIED procedures from October 1, 2007 to September 30, 2013 and had procedural information entered into the VA Clinical Assessment Reporting and Tracking (CART) software program were included in this study. All antibiotic prescriptions lasting more than 24 hours following device implantation or revision were identified using pharmacy databases, and postprocedural antibiotic use lasting more than 24 hours was characterized.
RESULTSIn total, 3,712 CIED procedures were performed at 34 VA facilities on 3,570 patients with a mean age of 71.7 years (standard deviation [SD], 11.1 years), 98.4% of whom were male. Postprocedural antibiotics >24 hours were prescribed following 1,579 of 3,712 CIED procedures (42.5%). The median duration of therapy was 5 days (interquartile range [IQR], 3–7 days). The most commonly prescribed antibiotic was cephalexin (1,152 of 1,579; 72.9%), followed by doxycycline (118 of 1,579; 7.47%) and ciprofloxacin (93 of 1,579; 5.9%). Vancomycin was used in 73 of 1,579 prescriptions (4.62%). Among the highest quartile of procedural volume, prescribing practices varied considerably, ranging from 3.2% to 77.6%.
CONCLUSIONSNearly 1 in 2 patients received prolonged postprocedural antimicrobial therapy following CIED procedures, and the rate of postprocedural antimicrobial therapy use varied considerably by facility. Given the lack of demonstrated benefit of routine prolonged antimicrobial therapy following CIED procedures, antimicrobial use following cardiac device interventions may be a potential target for quality improvement programs and antimicrobial stewardship.
Infect Control Hosp Epidemiol 2016;37:1005–1011