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Hospital-Level Variability in Broad-Spectrum Antibiotic Use for Children With Acute Leukemia Undergoing Hematopoietic Cell Transplantation
- Caitlin W. Elgarten, Staci D. Arnold, Yimei Li, Yuan-Shung V. Huang, Marcie L. Riches, Jeffrey S. Gerber, Richard Aplenc, Wael Saber, Brian T. Fisher
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- Journal:
- Infection Control & Hospital Epidemiology / Volume 39 / Issue 7 / July 2018
- Published online by Cambridge University Press:
- 08 May 2018, pp. 797-805
- Print publication:
- July 2018
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OBJECTIVE
To explore the prevalence and drivers of hospital-level variability in antibiotic utilization among hematopoietic cell transplant (HCT) recipients to inform antimicrobial stewardship initiatives.
DESIGNRetrospective cohort study using data merged from the Pediatric Health Information System and the Center for International Blood and Marrow Transplant Research.
SETTINGThe study included 27 transplant centers in freestanding children’s hospitals.
METHODSThe primary outcome was days of broad-spectrum antibiotic use in the interval from day of HCT through neutrophil engraftment. Hospital antibiotic utilization rates were reported as days of therapy (DOTs) per 1,000 neutropenic days. Negative binomial regression was used to estimate hospital utilization rates, adjusting for patient covariates including demographics, transplant characteristics, and severity of illness. To better quantify the magnitude of hospital variation and to explore hospital-level drivers in addition to patient-level drivers of variation, mixed-effects negative binomial models were also constructed.
RESULTSAdjusted hospital rates of antipseudomonal antibiotic use varied from 436 to 1121 DOTs per 1,000 neutropenic days, and rates of broad-spectrum, gram-positive antibiotic use varied from 153 to 728 DOTs per 1,000 neutropenic days. We detected variability by hospital in choice of antipseudomonal agent (ie, cephalosporins, penicillins, and carbapenems), but gram-positive coverage was primarily driven by vancomycin use. Considerable center-level variability remained even after controlling for additional hospital-level factors. Antibiotic use was not strongly associated with days of significant illness or mortality.
CONCLUSIONAmong a homogenous population of children undergoing HCT for acute leukemia, both the quantity and spectrum of antibiotic exposure in the immediate posttransplant period varied widely. Antimicrobial stewardship initiatives can apply these data to optimize the use of antibiotics in transplant patients.
Infect Control Hosp Epidemiol 2018;797–805
Contributors
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- By Nalini Vadivelu, Christian J. Whitney, Raymond S. Sinatra, M. Khurram Ghori, Yu-Fan (Robert) Zhang, Raymond S. Sinatra, Joshua Wellington, Yuan-Yi Chia, Francis J. Keefe, Jon McCormack, Ian Power, John Butterworth, P. M. Lavand’homme, M. F. De Kock, Bradley Urie, Oscar A. de Leon-Casasola, Frederick M. Perkins, Larry F. Chu, David Clark, Martin S. Angst, Cynthia M. Welchek, Lisa Mastrangelo, Raymond S. Sinatra, Richard Martinez, Scott S. Reuben, Asokumar Buvanendran, Raymond S. Sinatra, Pamela E Macintyre, Julia Coldrey, Daniel B. Maalouf, Spencer S. Liu, Susan Dabu-Bondoc, Samantha A. Franco, Raymond S. Sinatra, James Benonis, Jennifer Fortney, David Hardman, Gavin Martin, Holly Evans, Karen C. Nielsen, Marcy S. Tucker, Stephen M. Klein, Benjamin Sherman, Ikay Enu, Raymond S. Sinatra, James W. Heitz, Eugene R. Viscusi, Jonathan S. Jahr, Kofi N. Donkor, Raymond S. Sinatra, Manzo Suzuki, Johan Raeder, Vegard Dahl, Stefan Erceg, Keun Sam Chung, Kok-Yuen Ho, Tong J. Gan, Dermot R. Fitzgibbon, Paul Willoughby, Brian E. Harrington, Joseph Marino, Tariq M. Malik, Raymond S. Sinatra, Giorgio Ivani, Valeria Mossetti, Simona Italiano, Thomas M. Halaszynski, Nousheh Saidi, Javier Lopez, Kate Miller, Ferne Braveman, Jaya L. Varadarajan, Steven J. Weisman, Sukanya Mitra, Raymond S. Sinatra, Theodore J. Saclarides, Knox H. Todd, James R. Miner, Chris Pasero, Nancy Eksterowicz, Margo McCaffery, Leslie N. Schechter, Amr E. Abouleish, Govindaraj Ranganathan, Tee Yong Tan, Stephan A. Schug, Marie N. Hanna, Spencer S. Liu, Christopher L. Wu, Craig T. Hartrick, Garen Manvelian, Christine Miaskowski, Brian Durkin, Peter S. A. Glass
- Edited by Raymond S. Sinatra, Oscar A. de Leon-Cassasola, University of Rochester Medical Center, New York, Eugene R. Viscusi, Brian Ginsberg
- Foreword by Henry McQuay
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- Book:
- Acute Pain Management
- Published online:
- 26 October 2009
- Print publication:
- 27 April 2009, pp vii-xii
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6 - Alternative Knowledge Structures in Creative Thought: Schema, Associations, and Cases
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- By Michael D. Mumford, Department of Psychology, University of Oklahoma, Norman, Oklahoma, Cassie S. Blair, Department of Psychology, University of Oklahoma, Norman, Oklahoma, Richard T. Marcy, Department of Psychology, University of Oklahoma, Norman, Oklahoma
- Edited by James C. Kaufman, California State University, San Bernardino, John Baer, Rider University, New Jersey
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- Book:
- Creativity and Reason in Cognitive Development
- Published online:
- 19 January 2010
- Print publication:
- 29 May 2006, pp 117-136
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Summary
A number of approaches might be used to understand how people think creatively. One might, for example, examine the performance characteristics associated with certain problem-solving tasks known to elicit creative thought (Mumford, 2002). One might try to identify the abilities people must posses if they are to solve creative problems (Sternberg & O'Hara, 1999). And, one might examine the errors people make as they work through problems calling for creative thought (Carlson & Gorman, 1992).
Although these alternative approaches all have value, process analysis remains the dominant approach in studies of creative thought (Brophy, 1998; Lubart, 2001). In process studies, an attempt is made to identify the major cognitive operations that occur as people work on the complex, novel, ill-defined tasks that call for creative thought and the production of original, albeit useful, products (Ghiselin, 1963; Mace & Ward, 2002; Ward, Smith, & Finke, 1999). The attraction of the process approach is because of both its generality and the framework provided for identifying the heuristics, or strategies, needed at each step in peoples' creative efforts.
Over the years, a number of models describing the processes involved in creative thought have been proposed (Dewey, 1910; Merrifield, Guilford, Christensen, & Frick, 1962; Parnes & Noller, 1972; Sternberg, 1985; Wallas, 1926). In a review of this literature, Mumford and his colleagues (Mumford, Mobley, Uhlman, Reiter-Palmon, & Doares, 1991; Mumford, Peterson, & Childs, 1999) identified eight core process that appeared to be involved in most real-world creative problem-solving efforts: (1) problem construction, (2) information gathering, (3) concept selection, (4) conceptual combination, (5) idea generation, (6) idea evaluation, (7) implementation planning, and (8) monitoring.