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Characteristics Associated with Death in Patients with Carbapenem-Resistant Acinetobacter baumannii, United States, 2012–2017
- Hannah E. Reses, Kelly Hatfield, Jesse Jacob, Chris Bower, Elisabeth Vaeth, Jacquelyn Mounsey, Daniel Muleta, Medora Witwer, Ghinwa Dumyati, Emily Hancock, James Baggs, Maroya Walters, Sandra Bulens
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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. s59-s60
- Print publication:
- October 2020
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Background: Carbapenem-resistant Acinetobacter baumannii (CRAB) is an important cause of healthcare-associated infections with limited treatment options and high mortality. To describe risk factors for mortality, we evaluated characteristics associated with 30-day mortality in patients with CRAB identified through the Emerging Infections Program (EIP). Methods: From January 2012 through December 2017, 8 EIP sites (CO, GA, MD, MN, NM, NY, OR, TN) participated in active, laboratory-, and population-based surveillance for CRAB. An incident case was defined as patient’s first isolation in a 30-day period of A. baumannii complex from sterile sites or urine with resistance to ≥1 carbapenem (excluding ertapenem). Medical records were abstracted. Patients were matched to state vital records to assess mortality within 30 days of incident culture collection. We developed 2 multivariable logistic regression models (1 for sterile site cases and 1 for urine cases) to evaluate characteristics associated with 30-day mortality. Results: We identified 744 patients contributing 863 cases, of which 185 of 863 cases (21.4%) died within 30 days of culture, including 113 of 257 cases (44.0%) isolated from a sterile site and 72 of 606 cases (11.9%) isolated from urine. Among 628 hospitalized cases, death occurred in 159 cases (25.3%). Among hospitalized fatal cases, death occurred after hospital discharge in 27 of 57 urine cases (47.4%) and 21 of 102 cases from sterile sites (20.6%). Among sterile site cases, female sex, intensive care unit (ICU) stay after culture, location in a healthcare facility, including a long-term care facility (LTCF), 3 days before culture, and diagnosis of septic shock were associated with increased odds of death in the model (Fig. 1). In urine cases, age 40–54 or ≥75 years, ICU stay after culture, presence of an indwelling device other than a urinary catheter or central line (eg, endotracheal tube), location in a LTCF 3 days before culture, diagnosis of septic shock, and Charlson comorbidity score ≥3 were associated with increased odds of mortality (Fig. 2). Conclusion: Overall 30-day mortality was high among patients with CRAB, including patients with CRAB isolated from urine. A substantial fraction of mortality occurred after discharge, especially among patients with urine cases. Although there were some differences in characteristics associated with mortality in patients with CRAB isolated from sterile sites versus urine, LTCF exposure and severe illness were associated with mortality in both patient groups. CRAB was associated with major mortality in these patients with evidence of healthcare experience and complex illness. More work is needed to determine whether prevention of CRAB infections would improve outcomes.
Funding: None
Disclosures: None
3453 The Spectrum of Homelessness and Its Association with Maternal Morbidity
- Kelley N. Robinson, Kelly Bower, Jennifer Stewart, Nancy Perrin, Nancy Glass, Keshia Pollack-Porter, Phyllis Sharps
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- Journal:
- Journal of Clinical and Translational Science / Volume 3 / Issue s1 / March 2019
- Published online by Cambridge University Press:
- 26 March 2019, pp. 96-97
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OBJECTIVES/SPECIFIC AIMS: To examine maternal morbidity and its related social determinants among women experiencing homelessness during pregnancy. METHODS/STUDY POPULATION: This study will use an exploratory sequential mixed method design to explore and examine the structural, interpersonal and individual factors contributing to maternal morbidity among a convenience sample of 150 English speaking women experiencing homelessness during a pregnancy within the last 3 years in Baltimore. In the qualitative phase of the study, we will conduct semi-structured interviews with 15 women purposively sampled to refine the relationships between resilience, social determinants of health and multilevel factors that impact maternal morbidities. Factors of interest include prenatal care received, barriers and facilitators to receiving prenatal care, maternal morbidities, social support, and strategies used to manage their condition during this time. Using the findings from the qualitative phase, a quantitative survey will be developed to gather data on topics that emerged in the interviews. In addition, the Housing Instability Index will be used to measure the degree of homelessness as defined by the degree of housing instability in a 6-month period. Using the 25-item Connor-Davidson Resilience Scale, resilience levels among women in the sample will be assessed as a moderating factor in the examination of the relationship between a pregnant woman’s homeless status and maternal morbidity. Descriptive statistics and logistical regression tests will be used to analyze these relationships while controlling for other structural, interpersonal, and individual factors that may be associated with maternal morbidity. RESULTS/ANTICIPATED RESULTS: Qualitatively we expect to gain insight into the relationship between the extrinsic and intrinsic factors impacting maternal morbidities and the health behaviors and practices used by women to manage their pregnancy while homeless. These findings will inform the quantitative survey development and help generalize the quantitative findings. We expect to identify the common morbidities in this population we anticipate that there will be differences in maternal morbidity among the different types of homelessness. Maternal morbidity will be higher among women with a greater degree of homelessness. Resilience will have a moderating effect on the relationship between homelessness and maternal morbidity. DISCUSSION/SIGNIFICANCE OF IMPACT: This study, to our knowledge, is the first to look at maternal morbidity in this population. Additionally, this study seeks to move current research from examining infant outcomes at birth among mothers experiencing homelessness to understanding the maternal morbidities during this period. Long term, good maternal health has significant implications for the health of a mother’s future pregnancies and a risk reduction of adverse chronic conditions. Study results will provide the preliminary knowledge needed to guide further research leading to clinical approaches that promote better maternal health in this population. Lastly, the study findings will inform policy by characterizing the quality and strength of evidence of the adverse maternal health effects associated with the experience of homelessness.
2381 Childhood adversity, attachment style, and home visiting engagement
- Kelly M. Bower, Deborah Gross, Phyllis Sharps
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- Journal:
- Journal of Clinical and Translational Science / Volume 2 / Issue S1 / June 2018
- Published online by Cambridge University Press:
- 21 November 2018, p. 65
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OBJECTIVES/SPECIFIC AIMS: This case-control study aims to determine the relationships among childhood adversity, attachment style, and the likelihood of accepting or declining a referral for HV. The study will serve as a pilot to inform the power analysis of a subsequently proposed full-scale study. METHODS/STUDY POPULATION: Using a case-control study design, 25 women who decline HV referral (cases) will be compared with 25 women who accept HV referral (controls) on their exposure to childhood adversity and attachment style. Women who are eligible for the study are English-speaking mothers who have been offered HV services by Health Care Access Maryland. Surveys are administered in-person, either in the participant’s home or at another location (e.g., public library), based on participant preference. The dependent variable is participant’s verbal response to the HV referral (accept/decline). The independent variable, childhood adversity, will be measured using the Philadelphia Urban Adverse Childhood Experiences (ACEs) Survey and the Attachment Style Questionnaire (ASQ). Control variables include demographics (i.e., age, race, education, employment, housing, marital status), obstetric history (i.e., previous preterm birth, miscarriage, fetal death, infant death, abortion), and current psychosocial risk factors (i.e., history of substance use, intimate partner violence, depression). Descriptive comparisons will be done for the independent and control variables in controls versus cases. Bivariate analysis will examine associations between the odds of being a case and ACE score and ASQ score. Multivariate logistic regression models will be used to examine the relationship between ACE total and ASQ score; exposure to ACE in cases versus controls; and the odds of an avoidant and anxious attachment styles in cases versus controls. RESULTS/ANTICIPATED RESULTS: We hypothesize that (a) higher ACE scores will be positively associated with a higher level of avoidant attachment; (b) higher ACE scores will be positively associated with declining a HV referral; and (c) higher levels of avoidant attachment will be associated with declining a HV referral. DISCUSSION/SIGNIFICANCE OF IMPACT: Racial inequities in birth outcomes are pervasive and unjust. Non-Hispanic Black women experience births that result in infant mortality, fetal mortality, preterm birth, and low birth weight babies at more than double the rate of non-Hispanic White women in Baltimore and nationally. Prenatal and early childhood home visiting programs have been found to decrease maternal smoking and hypertensive disorder which are associated with PTB, reduce closely spaced births which is associated with fetal and infant death, and improve women’s long-term economic self-sufficiency, child health and social outcomes. However, as community-based programs, these services are not reaching the majority of eligible women in low-income urban settings—women who are also disproportionately burdened with poor pregnancy-related health outcomes. Considering the potential to improve outcomes, the importance of eliminating health disparities, and the national and local investment in HV services, it is vital to understand why some women are not enrolling in prenatal HV programs. The findings from this and subsequent studies will inform the translation of evidence-based HV program outreach efforts for women with complex social history. It will inform the design of enhanced outreach and engagement efforts of HV programs to more reliably engage women.
2358: Association of medical and psychosocial risk factors with engagement in prenatal home visiting
- Kelly M. Bower, Deborah Gross, Margaret Ensminger, Jana Goins, Phyllis Sharps
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- Journal:
- Journal of Clinical and Translational Science / Volume 1 / Issue S1 / September 2017
- Published online by Cambridge University Press:
- 10 May 2018, p. 27
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OBJECTIVES/SPECIFIC AIMS: The purpose of this study is to understand factors that are associated with identifying which eligible pregnant women in Baltimore City accept a referral for HV services. Taking into account demographic and obstetrical variables, we will examine the extent to which 13 medical and 14 psychosocial risk factors differentiate pregnant women who (1) accepted a HV referral, (2) could not be located, or (3) refused a HV referral. METHODS/STUDY POPULATION: In this observational study, we will use secondary data on 8172 pregnant women collected by Health Care Access Maryland (HCAM) between 2014 and 2016. HCAM is the single point of entry for all pregnant women in Baltimore City into HV. HV eligibility includes being a pregnant woman, residing in Baltimore City, being uninsured or receiving Medicaid, and being identified by a prenatal care provider who completed an assessment profile of the woman’s medical and psychosocial risk (prenatal risk assessment). The outcome variable, HV engagement status (ie, accepted referral, could not be located, refused referral), will be based on HCAM discharge codes. Medical risk factors include BMI, hypertension, anemia, asthma, sickle cell, diabetes, vaginal bleeding, genetic risk, sexually transmitted disease, last dental visit >1 year ago, and taking prescription medications. Psychosocial risk factors include current pregnancy unintended; <1 year since last delivery; late entry to prenatal care (>20 wk gestation); mental, physical, or developmental disability; history of abuse or violence within past 6 months; tobacco use; alcohol use; illegal substance use within the past 6 months; resides in home built before 1978; homelessness; lack of social/emotional support; exposure to long-term stress; lack of transportation; and history of depression or mental illness. All risk factor variables are categorical (yes/no). Control variables will include demographics (eg, age, race, ethnicity, marital status, educational level) and OB history (eg, history of preterm labor, history of fetal or infant death). We will conduct descriptive statistics to characterize the sample and look for interrelatedness among the risk factors. Where there is a high level of inter-relatedness we will consider combining or omitting variables to reduce redundancy. We will use multinomial regression to examine which medical and psychological factors are associated with referral category. RESULTS/ANTICIPATED RESULTS: We hypothesize that (a) women with more medical risk factors will be more likely to accept a referral for HV services, (b) women with more psychosocial risk factors will be more likely to refuse HV or not be located, and (c) certain risk factors, such as depression/mental illness, history of abuse/violence, illegal substance use, homelessness, and exposure to long-term stress will be the strongest predictors of not accepting HV referral and/or not being located. DISCUSSION/SIGNIFICANCE OF IMPACT: The translation of effective randomized control trials (RCTs) to successful implementation in community-based programs can be challenging. Community-based programs serving low-income communities typically lack the same resources available to recruit and retain participants in RCTs. And, exclusion criteria applied in RCTs are often not applied in real world implementation which can open program to participants with more complex social and medical characteristics. Findings from this study will inform the translation of evidence-based HV programs into real world settings through an enhanced understanding of the characteristics of women who are not engaged by HV programs. This will inform development of improved outreach methods that may more effectively engage at-risk women for prenatal HV services.