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Cost Savings Associated With Decolonization of Postdischarge MRSA Carriers: Results From the CLEAR Randomized Trial
- Natasha K. Stout, Grace M. Lee, Anastasiia S. Weiland, Caleb S. Chen, Syma Rashid, Raveena D. Singh, Thomas Tjoa, Jiayi He, James A. McKinnell, Loren G. Miller, Susan S. Huang
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- Journal:
- Infection Control & Hospital Epidemiology / Volume 41 / Issue S1 / October 2020
- Published online by Cambridge University Press:
- 02 November 2020, pp. s28-s29
- Print publication:
- October 2020
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Background: Greater than 10% of hospitalized MRSA carriers experience serious MRSA infection in the year following discharge. Prevention opportunities have primarily focused on hospital stays; however postdischarge interventions have the potential to reduce morbidity, mortality and healthcare costs. The CLEAR trial found a 30% hazard reduction in postdischarge MRSA infections among patients who had inpatient MRSA cultures and were given postdischarge decolonization (5 days twice-a-month for 6 months) relative to hygiene education alone. We conducted a cost analysis of the CLEAR intervention to quantify the economic implications and understand the value of adopting this MRSA decolonization strategy. Methods: We constructed a decision model to estimate the one-year healthcare utilization and costs associated with postdischarge decolonization relative to hygiene education. Trial results for MRSA infection risk and downstream outcomes (including outpatient and emergency room visits, hospitalizations, related nursing home stays, and postdischarge antibiotics) were used to parameterize the model. Other medical care and prescription drug costs were based on Medicare Fee Schedules, Red Book and the literature. Patient out-of-pocket costs and time costs associated with subsequent infections were from a survey of trial participants experiencing infection (n=405). All costs were reported in 2019 US dollars. The analysis was conducted using healthcare system and societal perspectives. Sensitivity analyses were conducted on key parameters. Results: Among a hypothetical cohort of 1,000 hospitalized MRSA carriers, we estimated that a postdischarge decolonization intervention versus hygiene education would result in at least 36 fewer subsequent MRSA infections (130 vs 93 of 1,000, respectively) and >40 fewer MRSA-attributable healthcare events including 32 hospitalizations and 6 postdischarge nursing home visits over the course of a year. Assuming an intervention cost of $185 per individual, the program would result in an overall cost savings of $469,000 per 1,000 MRSA carriers undergoing decolonization. This translates to an overall savings of $13,200 per infection averted and $9,000 per infection averted from the healthcare system perspective. Even assuming a lower infection rate or a less effective intervention (15% reduction in infections vs 30% in the CLEAR trial), or a more expensive (up to $653 per patient) intervention, a decolonization program would still result in cost-savings for society, the healthcare system and patients. Conclusions: In addition to health benefits of preventing infections, postdischarge decolonization of MRSA carriers yields substantial savings to society and the healthcare system. Future recommendations for reducing postdischarge MRSA-related disease among MRSA carriers should consider routine decolonization at hospital discharge.
Funding: This study was supported by a grant from the AHRQ Healthcare-Associated Infections Program (R01HS019388) and by the University of California Irvine Institute for Clinical and Translational Science, which was funded by a grant from the NIH Clinical and Translational Sciences Award program (UL1 TR000153).
Disclosures: Dr. Huang reports conducting clinical studies in which participating nursing homes and hospitals received donated products from Stryker (Sage Products), Mölnlycke, 3M, Clorox, Xttrium Laboratories, and Medline. Ms. Singh reports conducting clinical studies in which participating nursing homes and hospitals received donated products from Stryker (Sage Products), 3M, Clorox, Xttrium Laboratories, and Medline. Dr. Rashid, conducting clinical studies in which participating nursing homes and hospitals received donated products from Stryker(Sage Products), Clorox, and Medline. Dr. McKinnell reports receiving grant support to his institution from Melinta Therapeutics, and fees for serving as a research investigator from Lightship, conducting clinical studies in which participating nursing homes and hospitals received donated products from Stryker (Sage Products), 3M, Clorox, Xttrium Laboratories and Medline, and serving as cofounder of Expert Stewardship. Dr. Miller reports receiving grant support from Gilead Sciences, Merck, Abbott, Cepheid, Genentech, Atox Bio, and Paratek Pharmaceuticals, grant support and fees for serving on an advisory board from Achaogen and grant support, consulting fees, and fees for serving on an advisory board from Tetraphase and conducting clinical studies in which participating nursing homes and hospitals received donated products from Stryker (Sage Products), 3M, Clorox, Xttrium Laboratories, and Medline.
Unintended Consequences of MRSA Infection: Empiric Non-MRSA Antibiotic Use and Resultant Clostridioides difficile Infection
- Anastasiia S. Weiland, Julia Y. Lu, Caleb S. Chen, Thomas Tjoa, Raveena D. Singh, James A. McKinnell, UCLA Medical Center, Loren Miller, Susan Huang
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- Journal:
- Infection Control & Hospital Epidemiology / Volume 41 / Issue S1 / October 2020
- Published online by Cambridge University Press:
- 02 November 2020, pp. s421-s422
- Print publication:
- October 2020
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Background: Methicillin-resistant Staphylococcus aureus (MRSA) is responsible for the largest number of invasive infections due to a multidrug-resistant pathogen. Approximately 10% of hospitalized carriers will experience invasive MRSA disease in the year following discharge incurring antibiotic therapy beyond focused treatment of MRSA. Objective: We aimed to quantify the extent of non-MRSA empiric antibiotics incurred by MRSA infections and further assess the risk of Clostridioides difficile Infection (CDI) as a result of treatment of MRSA infection. Methods: The CLEAR Trial was a postdischarge randomized controlled trial of 2,121 MRSA carriers comparing MRSA education alone to education plus repeated decolonization that demonstrated a 30% reduction in MRSA infection and a 17% reduction in all-cause infection attributable to decolonization in the year following hospital discharge (Huang SS, NEJM 2019). We included all hospitalization outcomes due to MRSA infection in the CLEAR Trial with detailed medication administration records to quantify unintended consequences of MRSA infection related to empiric non-MRSA antibiotic use and resultant CDI. Full-text medical records were reviewed with a standardized abstraction form to collect inpatient administered antibiotics and hospital-associated CDI. Results: In total,154 hospitalizations due to MRSA infection with a mean length-of-stay of 10.6 days were identified. During 25 hospitalizations (16.2%), patients received only anti-MRSA antibiotics. During the remaining 129 (83.8%) hospitalizations, patients received a mean of 1.6 distinct non-MRSA antibiotics totaling a mean of 6.6 days of therapy (DOT). Empiric non-MRSA therapy was given for 3.2 DOT before MRSA culture results became available and was continued for an additional 3.4 DOT afterward. Among all 849 non-MRSA DOT, the most common were due to piperacillin-tazobactam (293 DOT, 34.5%), levofloxacin (105 DOT, 12.4%), and metronidazole (93 DOT, 11.0%). Across all 154 hospitalizations, a mean of 5.5 non-MRSA DOT was calculated per MRSA hospitalization, with 6 CDI cases (3.9%) as a direct sequelae of empiric non-MRSA antibiotics provided for MRSA infection. Conclusions: Hospitalization for MRSA infection results in extensive non-MRSA empiric antibiotic therapy both before and after MRSA culture results are known. This antibiotic use is associated with a 3.9% risk of CDI that exceeds the national risk of acquiring CDI (3.2 per 1,000 admissions) by 12-fold during any hospital stay (Barrett ML, AHRQ 2018). The CLEAR Trial findings that postdischarge decolonization reduces MRSA infection and hospitalization by 30% suggests that decolonization may also reduce non-MRSA antibiotic use and CDI in this population.
Funding: None
Disclosures: None
Improved Biphasic Pulsing Power Efficiency with Pt-Ir Coated Microelectrodes
- Artin Petrossians, Navya Davuluri, John J. Whalen III, Florian Mansfeld, James D. Weiland
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- Journal:
- MRS Online Proceedings Library Archive / Volume 1621 / 2014
- Published online by Cambridge University Press:
- 28 February 2014, pp. 249-257
- Print publication:
- 2014
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Neuromodulation devices such as deep brain stimulators (DBS), spinal cord stimulators (SCS) and cochlear implants (CIs) use electrodes in contact with tissue to deliver electrical pulses to targeted cells. In general, the neuromodulation industry has been evolving towards smaller, less invasive devices. Improving power efficiency of these devices can reduce battery storage requirements. Neuromodulation devices can realize significant power savings if the impedance to charge transfer at the electrode-tissue interface can be reduced. High electrochemical impedance at the surface of stimulation microelectrodes results in larger polarization voltages. Decreasing this polarization voltage response can reduce power required to deliver the current pulse. One approach to doing this is to reduce the electrochemical impedance at the electrode surface. Previously we have reported on a novel electrochemically deposited 60:40% platinum-iridium (Pt-Ir) electrode material that lowered the electrode impedance by two orders of magnitude or more.
This study compares power consumption of an electrochemically deposited Pt-Ir stimulating microelectrode to that of standard Pt-Ir probe microelectrode produced using conventional techniques. Both electrodes were tested using in-vitro in phosphate buffered saline (PBS) solution and in-vivo (live rat) models.
High-Density Feedthrough Technology for Hermetic Biomedical Micropackaging
- Emma C. Gill, John Antalek, Fred M. Kimock, Patrick J. Nasiatka, Ben P. McIntosh, Armand R. Tanguay, Jr., James D. Weiland
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- Journal:
- MRS Online Proceedings Library Archive / Volume 1572 / 2013
- Published online by Cambridge University Press:
- 10 June 2013, mrss13-1572-ss05-08
- Print publication:
- 2013
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Implantable electronic biomedical devices are used clinically to diagnose and treat an increasing number of medical conditions. Such devices typically employ hermetic packages that often incorporate electrical feedthroughs made with conventional ceramic-to-metal bonding technologies. This sealing technology is well established and provides robust hermetic seals, but is limited in both the number and spacing of electrical leads. Emerging devices for interfacing with the human nervous system, however, will require a large number of external electrical leads implemented in a miniaturized packaging configuration. Commercially available feedthrough technologies are currently incapable of providing external electrical contacts with spacings as small as 200 to 400 microns, and thus are neither compatible with integrated circuit I/O (input/output) pad spacings nor with miniature implantable packages. We report the development of a hermetic high-density feedthrough (HDF) technology that allows for conductive path densities as high as 1,000 per cm2, and that is capable of supporting neural interface devices. The fabrication process utilizes multilayer high temperature co-fired ceramic (HTCC) technology in conjunction with platinum leads. Before co-firing, green alumina substrates are interleaved with linear, parallel Pt trace arrays in either wire or thin foils to form the electrical feedthroughs. Layered stacks of spatially isolated traces are first compacted into a composite, and then fired to achieve densification. After firing, the densified multilayered composite compacts are sliced perpendicular to the Pt traces and lapped to produce multiple feedthrough arrays with a high density of leads (conductors). Both hermeticity and biocompatibility of such implantable feedthroughs are important, as both moisture and positive mobile ion contamination from the saline environment of the human body can lead to compromised performance or catastrophic failure. HDFs fabricated using this process with 100 conductors and lead-to-lead spacings as low as 400 microns have been helium leak tested repeatedly and found to exceed industry-accepted standards with helium leak rates in the range of 10–11 mbar-l/s. The spacing of the current prototype matches industry standard neural interface technology, and can be scaled to higher densities with lead-to-lead spacings as small as 200 microns. The reported HDF process has several distinct advantages over prior approaches, including the provision of a large number of conductive feedthrough leads suitable for flip-chip bonding with sub-mm lead-to-lead spacings (pitch), and the incorporation of materials (alumina and platinum) that are already used in medical implants. The implementation of such an HDF technology allows for significant package miniaturization, allowing greater flexibility in surgical placement as well as less invasive procedures for implantable electronic biomedical devices.