6 results
Staphylococcal Decolonization to Prevent Surgical Site Infection: Is There a Role in colorectal surgery?
- Rasha Raslan, Michelle Elizabeth Doll, Heather Albert, Hirsh Shah, Kaila Cooper, Emily Godbout, Michael Stevens, Gonzalo Bearman
-
- Journal:
- Infection Control & Hospital Epidemiology / Volume 41 / Issue S1 / October 2020
- Published online by Cambridge University Press:
- 02 November 2020, p. s497
- Print publication:
- October 2020
-
- Article
-
- You have access Access
- Export citation
-
Background: Colorectal surgery is associated with a high risk of surgical site infections (SSIs), with an incidence ranging from 16.9% to 20%, and SSIs are associated with significant morbidity and mortality, prolonged length of hospitalization, and increased health care costs. Staphylococcal decolonization is an attempt to alter the microbiome to prevent staphylococcal and other skin flora from accessing the surgical site, and This practice effectively reduces SSIs in orthopedic, neurologic, and cardiac surgeries. A staphylococcal decolonization protocol was enacted in colorectal surgeries at our institution beginning in October 2016. We compared patient outcomes between patients who did and did not undergo preoperative staphylococcal decolonization. Methods: All patients undergoing nonemergent NHSN-defined colorectal procedures from July 2015 until June 2019 at a tertiary-care medical center were included in this retrospective study. Staphylococcal decolonization was performed using chlorhexidine 2% body wash solution, mupirocin nasal ointment, and chlorhexidine 0.12% oral rinse all twice daily for 5 days prior to surgery. All SSIs were defined by NSHN criteria. The primary outcome was SSI, and secondary outcomes were superficial wound infection (SIP) and organ-space infection (IAB). Predictive variables included decolonization status (yes or no), age, gender, body mass index, procedure duration, American Society of Anesthesiologists (ASA) score, diabetes, smoking, and surgical oncology service. Surgical antimicrobial prophylaxis with cefazolin and metronidazole OR cefoxitin, and chlorhexidine skin preparation were standard throughout the study period. Univariate analysis was performed using a χ2 or t test. Multivariable logistic regression was performed to control for all clinically important variables above. All statistical analyses were done using SAS version 9.4 software (Cary, NC). Results: In total, 1,139 patients underwent nonemergent colorectal surgery from July 2015 to June 2019. There were 74 SSIs: 42 IABs and 32 SIPs. Decolonization was performed in 332 of 1,139 cases (29%). There was no difference in overall SSIs between those decolonized and not decolonized (P = .50). However, SIPs were reduced in the group receiving decolonization: 1.2% (4 of 332) versus 3.5% (28 of 807) (P = .04. When controlling for known SSI risk factors, those not receiving decolonization remained at increased risk of SIPs (OR, 3.79; 95% CI, 1.14–12.61; P = .03. Conclusions: Staphylococcal decolonization may prevent a subset of SSIs in patients undergoing colorectal surgery.
Funding: None
Disclosures: Michelle Doll reports a research Grant from Molnlycke Healthcare.
A Descriptive Analysis of Outpatient Antimicrobial Use for Urinary Tract Infections in Virginia
- Hasti Mazdeyasna, Shaina Bernard, Le Kang, Emily Godbout, Kimberly Lee, Amy Pakyz, Andrew Noda, Jihye Kim, John Daniel Markley, Michelle Elizabeth Doll, Gonzalo Bearman, Michael Stevens
-
- Journal:
- Infection Control & Hospital Epidemiology / Volume 41 / Issue S1 / October 2020
- Published online by Cambridge University Press:
- 02 November 2020, pp. s453-s454
- Print publication:
- October 2020
-
- Article
-
- You have access Access
- Export citation
-
Background: Data regarding outpatient antibiotic prescribing for urinary tract infections (UTIs) are limited, and they have never been formally summarized in Virginia. Objective: We describe outpatient antibiotic prescribing trends for UTIs based on gender, age, geographic region, insurance payer and International Classification of Disease, Tenth Revision (ICD-10) codes in Virginia. Methods: We used the Virginia All-Payer Claims Database (APCD), administered by Virginia Health Information (VHI), which holds data for Medicare, Medicaid, and private insurance. The study cohort included Virginia residents who had a primary diagnosis of UTI, had an antibiotic claim 0–3 days after the date of the diagnosis and who were seen in an outpatient facility in Virginia between January 1, 2016, and December 31, 2016. A diagnosis of UTI was categorized as cystitis, urethritis or pyelonephritis and was defined using the following ICD-10 codes: N30.0, N30.00, N30.01, N30.9, N30.90, N30.91, N39.0, N34.1, N34.2, and N10. The following antibiotics were prescribed: aminoglycosides, sulfamethoxazole/trimethoprim (TMP-SMX), cephalosporins, fluoroquinolones, macrolides, penicillins, tetracyclines, or nitrofurantoin. Patients were categorized based on gender, age, location, insurance payer and UTI type. We used χ2 and Cochran-Mantel-Haenszel testing. Analyses were performed in SAS version 9.4 software (SAS Institute, Cary, NC). Results: In total, 15,580 patients were included in this study. Prescriptions for antibiotics by drug class differed significantly by gender (P < .0001), age (P < .0001), geographic region (P < .0001), insurance payer (P < .0001), and UTI type (P < .0001). Cephalosporins were prescribed more often to women (32.48%, 4,173 of 12,846) than to men (26.26%, 718 of 2,734), and fluoroquinolones were prescribed more often to men (53.88%, 1,473 of 2,734) than to women (47.91%, 6,155 of 12,846). Although cephalosporins were prescribed most frequently (42.58%, 557 of 1,308) in northern Virginia, fluoroquinolones were prescribed the most in eastern Virginia (50.76%, 1677 of 3,304). Patients with commercial health insurance, Medicaid, and Medicare were prescribed fluoroquinolones (39.31%, 1,149 of 2,923), cephalosporins (56.33%, 1,326 of 2,354), and fluoroquinolones (57.36%, 5,910 of 10,303) most frequently, respectively. Conclusions: Antibiotic prescribing trends for UTIs varied by gender, age, geographic region, payer status and UTI type in the state of Virginia. These data will inform future statewide antimicrobial stewardship efforts.
Funding: None
Disclosures: Michelle Doll reports a research grant from Molnlycke Healthcare.
Prevalence of Carbapenem-Resistant Enterobacteriaceae (CRE) at a Tertiary-Care Center in the United States
- Diane Heipel, Yvette Major, Carli Viola-Luqa, Michelle Elizabeth Doll, Michael Stevens, Kaila Cooper, Emily Godbout, Gonzalo Bearman
-
- Journal:
- Infection Control & Hospital Epidemiology / Volume 41 / Issue S1 / October 2020
- Published online by Cambridge University Press:
- 02 November 2020, pp. s494-s495
- Print publication:
- October 2020
-
- Article
-
- You have access Access
- Export citation
-
Background: Quantification of the magnitude of CRE both within a facility and regionally poses a challenge to healthcare institutions. Periodic point-prevalence surveys are recommended by the CDC CRE tool kit as a facility-level prevention strategy. A 2016 point-prevalence survey of 2 high-risk units at a tertiary-care center in the United States for CRE colonization found that all patients surveyed were negative for CRE. The infection prevention (IP) team repeated the study in 2019 to reassess the prevalence of CRE in the healthcare facility. Methods: A point-prevalence survey was performed in November 2019 on the same 2 high-risk units surveyed in 2016. A perirectal flocked swab was collected from all patients unless a patient refused and/or a contraindication to rectal swab was present. Swabs were inoculated onto HardyChrom TM CRE agar for incubation in ambient air at 35°C for 24 hours. Organism identification was performed using MALDI-TOF mass spectrometry on a MBT Smart by Bruker. Results: None of the patients on either high-risk unit was known to be colonized or infected with CRE at the time of the point-prevalence survey. Of 41 perirectal swabs collected, 4 (9.8%) were positive for CRE. None (0 of 20) were surgical ICU patients and 4 of 21 (19%) were medical ICU patients. All positive swabs revealed different organisms identified as follows: Escherichia coli, Enterobacter cloacae, Enterobacter kobai, and Enterobacter aerogenes. All 4 positive patients had had recent contact with multiple acute-care hospitals. Also, 2 had been transferred for liver transplant evaluation. None of these patients had received a carbapenem during their admission to the facility. Conclusion: CRE are increasingly identified in healthcare centers in the United States. Centers previously classified as low prevalence will need to maintain preventive strategies to limit transmission risks as colonized patients arrive in the facility for care. Adoption of a robust horizontal infection prevention program may be an effective strategy to avoid the spread of CRE.
Funding: None
Disclosures: Michelle Doll reports a research grant from Molnlycke Healthcare.
Changes in Nursing Team Composition and Risk of Device Associated Infection in Intensive Care Units
- Hirsh Shah, Shelley A Knowlson, Audrey Roberson, Emily Godbout, Michael Stevens, Gonzalo Bearman, Michelle Elizabeth Doll
-
- Journal:
- Infection Control & Hospital Epidemiology / Volume 41 / Issue S1 / October 2020
- Published online by Cambridge University Press:
- 02 November 2020, p. s465
- Print publication:
- October 2020
-
- Article
-
- You have access Access
- Export citation
-
Background: The relationship between nursing staffing and healthcare-associated infections (HAIs) has been explored previously, with conflicting results. Intensive care units increasingly struggle to maintain trained staff. In May 2019, clinical coordinator (CC) roles changed to include 50% of time in direct patient care rather than supportive roles. In this study, we used shift records to explore the impact of staffing on HAI risk. Methods: Daily staffing records from December 2018 August 2019 for the medical-respiratory unit (MRICU) and the cardiac surgery unit (CSICU) were reviewed. Both units staff a fixed 2:1 patient:nurse ratio (1:1 for specific cardiac surgeries). Staff deficiency was defined as assignments filled by nurses pulled from other units/supplemental/or CC roles. Staff support comprised nursing assistants and unit secretaries. Census, admissions, and complexity score for number of devices were used to estimate care acuity. In CSICU, additional points were added for continuous renal replacement therapy, extracorporeal membrane oxygenation, ventricular assist devices, transplant, operative cases. NHSN definitions were used for central-line–associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs). The Spearman correlation coefficient was used to determine relationship between staffing, acuity, and risk window for HAI (days 1–10 preinfection). Linear regression was used to determine whether staffing deficiencies and/or support associate with the risk window prior to HAI. The final model included census and complexity score as control variables. The statistical analysis was performed using SAS version 9.4 software (Cary, NC). Results: Overall, 8 HAIs occurred in the study period: medical-respiratory intensive care unit (MRICU: 3 CAUTIs and 1 CLABSI) and cardiac surgery intensive care unit (CSICU: 1 CAUTI and 3 CLABSIs). Staffing and census fluctuated daily (Table 1). Total number of nurses correlated with complexity scores (r = 0.35; P < .0001) and daily census (r = 0.31; P < .0001) in the CSICU, and the census (r = 0.12; P = .04) in the MRICU. Nursing deficiencies correlated with days 1–10 before infection (r = 0.20; P = .0013) in the CSICU. In the regression model for the CSICU, nursing deficiencies increased in the time prior to HAI (P = .004), and support staff decreased in the time prior to HAI (P = .034) while controlling for census and complexity. These relationships were not significant in the MRICU. Conclusion: The lack of core nurses to support the staffing structure in CSICU correlated with periods prior to CLABSI or CAUTI in this small, unit-based study. Failure to recruit and retain highly skilled core staff may produce HAI risks, particularly for CLABSI in specialized units.
Funding: None
Disclosures: Michelle Doll, Research Grant from Molnlycke Healthcare
Accuracy of the NHSN Central-Line–Associated Bloodstream Infections (CLABSIs) Definition: The Experience of Two Geographically Proximal Hospitals
- Carlene Muto, Pamela Louise Bailey, Amie Patrick, Barry John Rittmann, Rachel Pryor, Kaila Cooper, Michelle Elizabeth Doll, Michael Stevens, Gonzalo Bearman
-
- Journal:
- Infection Control & Hospital Epidemiology / Volume 41 / Issue S1 / October 2020
- Published online by Cambridge University Press:
- 02 November 2020, pp. s457-s458
- Print publication:
- October 2020
-
- Article
-
- You have access Access
- Export citation
-
Background: Central-line–associated blood stream infections (CLABSIs) are linked with significant morbidity and mortality. A NHSN laboratory-confirmed bloodstream infection (LCBSI) has specific criteria to ascribe an infection to the central line or not. The criteria used to associate the pathogen to another site are restrictive. This objective to better classify CLABSIs using enhanced criteria to gain a comprehensive understanding of the error so that appropriate reduction efforts are utilized. Methods: We conducted a retrospective review of medical records with NHSN-identified CLABSI from July 2017 to December 2018 at 2 geographically proximate hospitals. Trained infectious diseases personnel from tertiary-care academic medical centers, the University of Virginia Health System, a 600-bed medical center in Charlottesville, Virginia, and Virginia Commonwealth University Health System with 865 beds in Richmond, Virginia, reviewed charts. We defined “overcaptured” or O-CLABSI into different categories: O-CLABSI-1 is bacteremia attributable to a primary infectious source; O-CLABSI-2 is bacteremia attributable to neutropenia with gastrointestinal translocation not meeting mucosal barrier injury criteria; O-CLABSI-3 is a positive blood culture attributable to a contaminant; and O-CLABSI-4 is a patient injecting line, though not officially documented. Descriptive analyses were performed using the χ2 and the Fisher exact tests. Results: We found a large number of O-CLABSIs on chart review (79 of 192, 41%). Overall, 56 of 192 (29%) LCBSIs were attributable to a primary infectious source not meeting NHSN definition. O-CLABSI proportions between the 2 hospitals were statistically different; hospital A identified 34 of 59 (58%) of their NHSN-identified CLABSIs as O-CLABSIs, and hospital B identified a 45 of 133 (34%) as O-CLABSIs (P = .0020) (Table 1). When comparing O-CLABSI types, hospital B had a higher percentage of O-CLABSI-1 compared to hospital B: 76% versus 64%. Hospital A had a higher proportion of O-CLABSI-2: 21 versus 7%. Hospitals A and B had similar proportion of O-CLABSI-3: 15% versus 18%. These values were all statistically significant (P < .0001). Discussions: The results of these 2 geographically proximate systems indicate that O-CLABSIs are common. Attribution can vary significantly between institutions, likely depending on differences in incidence of true CLABSI, patient populations, protocols, and protocol compliance. These findings have implications for interfacility comparisons of publicly reported data. Most importantly, erroneous attribution can result in missed opportunity to direct patient safety efforts to the root cause of the bacteremia and could lead to inappropriate treatment.
Funding: None
Disclosures: Michelle Doll, Research Grant from Molnlycke Healthcare
Effect of Meropenem Restriction on Time Between Order and Administration in a Medical Intensive Care Unit
- Aline Le, Le Kang, Andrew Noda, Emily Godbout, John Daniel Markley, Kimberly Lee, Amy Pakyz, Jihye Kim, Michelle Elizabeth Doll, Gonzalo Bearman, Michael Stevens
-
- Journal:
- Infection Control & Hospital Epidemiology / Volume 41 / Issue S1 / October 2020
- Published online by Cambridge University Press:
- 02 November 2020, p. s470
- Print publication:
- October 2020
-
- Article
-
- You have access Access
- Export citation
-
Background: In this study, we assessed whether meropenem restriction led to delays in administration for patients in a medical intensive care unit (MICU) at a large tertiary-care urban teaching hospital. Methods: The antimicrobial stewardship program (ASP) at Virginia Commonwealth University Health System (VCUHS) requires approval for restricted antimicrobial orders placed between 8 a.m. and 9 p.m. Between 8 a.m. and 5 p.m. (daytime), authorized approvers include ASP and infectious diseases (ID) physicians. From 5 p.m. to 9 p.m. (evening) orders are approved by ID fellows. Orders were entered as Stat, Now, and Routine. Between 9 p.m. and 8 a.m. (night), patients receive doses without approval. Meropenem restriction began in mid-January 2018. Pre- and postmeropenem restriction periods were defined as February–December 2017 and February–December 2018. Meropenem use data were compared for adult patients in the MICU. A multivariable Cox regression model was implemented to compare (1) time from order entry to approval; (2) time from order approval to patient administration; (3) total time from order entry to patient administration, adjusting for order priority, approver (ASP, ID consult, ID fellow, pharmacy); and (4) time of day of order placement (day, eve, night). The analyses were performed using SAS version 9.4 software (SAS Institute, Cary, NC). Result: Time from order approval to patient administration was significantly decreased in the postrestriction period (HR, 1.840; P < .001) (Table 1). Stat orders were faster compared to routine orders for order entry to approval (HR, 1.735; P < .001), approval to administration (HR, 2.610; P < .001), and total time from order entry to administration (HR, 2.812; P < .001). No significant differences were found in time to approval by approving service. Time from order entry to approval was faster for nighttime orders than for daytime orders (HR, 1.399; P = .037). Conclusions: Our data indicate that the time from order entry to administration decreased following meropenem restriction in our MICU. More research is needed to identify the reason for this finding, but we postulate that this is due to an effect on drug administration prioritization within nursing workflow. These data will inform our local meropenem restriction efforts.
Funding: None
Disclosures: Michelle Doll reports a research grant from Molnlycke Healthcare.