5 results
Impact of oral vancomycin treatment duration on rate of Clostridioides difficile recurrence in patients requiring concurrent systemic antibiotics
- Diana Kwiatkowski, Kassandra Marsh, Alyson Katz, John Papadopoulos, Jonathan So, Vincent J. Major, Philip M. Sommer, Sarah Hochman, Yanina Dubrovskaya, Serena Arnouk
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- Journal:
- Infection Control & Hospital Epidemiology / Volume 45 / Issue 6 / June 2024
- Published online by Cambridge University Press:
- 30 January 2024, pp. 717-725
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- June 2024
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Background:
There is a paucity of data guiding treatment duration of oral vancomycin for Clostridiodes difficile infection (CDI) in patients requiring concomitant systemic antibiotics.
Objectives:To evaluate prescribing practices of vancomycin for CDI in patients that required concurrent systemic antibiotics and to determine whether a prolonged duration of vancomycin (>14 days), compared to a standard duration (10–14 days), decreased CDI recurrence.
Methods:In this retrospective cohort study, we evaluated adult hospitalized patients with an initial episode of CDI who were treated with vancomycin and who received overlapping systemic antibiotics for >72 hours. Outcomes of interest included CDI recurrence and isolation of vancomycin-resistant Enterococcus (VRE).
Results:Among the 218 patients included, 36% received a standard duration and 64% received a prolonged duration of treatment for a median of 13 days (11–14) and 20 days (16–26), respectively. Patients who received a prolonged duration had a longer median duration of systemic antibiotic overlap with vancomycin (11 vs 8 days; P < .001) and significantly more carbapenem use and infectious disease consultation. Recurrence at 8 weeks (12% standard duration vs 8% prolonged duration; P = .367), recurrence at 6 months (15% standard duration vs 10% prolonged duration; P = .240), and VRE isolation (3% standard duration vs 9% prolonged duration; P = .083) were not significantly different between groups. Discontinuation of vancomycin prior to completion of antibiotics was an independent predictor of 8-week recurrence on multivariable logistic regression (OR, 4.8; 95% CI, 1.3–18.1).
Conclusions:Oral vancomycin prescribing relative to the systemic antibiotic end date may affect CDI recurrence to a greater extent than total vancomycin duration alone. Further studies are needed to confirm these findings.
Targeted Staphylococcus aureus decolonization in acute inpatient and intensive care settings of an academic medical center
- David DiTullio, Courtney Takats, Sarah Hochman
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- Journal:
- Antimicrobial Stewardship & Healthcare Epidemiology / Volume 2 / Issue S1 / July 2022
- Published online by Cambridge University Press:
- 16 May 2022, p. s55
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Background:Staphylococcus aureus is a common cause of healthcare associated infections and is associated with high mortality. S. aureus colonization of skin and mucosa contributes to its pathogenesis. Universal S. aureus decolonization reduces methicillin-resistant S. aureus (MRSA) and other bloodstream infections among ICU patients. However, universal decolonization in acute-care settings has not shown a similar benefit. We describe a targeted decolonization protocol implemented at a large academic hospital across acute-care and intensive care settings. We assessed the impact of decolonization on S. aureus–related infections. Methods: Adults admitted in 2018–2019 to the medicine, oncology, transplant, and ICU services were screened for S. aureus colonization using nasal swabs for MRSA/MSSA by culture. Those with S. aureus detected underwent decolonization with 5 days of chlorhexidine 2% baths and mupirocin intranasal ointment. Decolonization was considered complete if given for 5 days. The primary outcome was S. aureus invasive infection from hospital day 3 until discharge, defined by positive clinical cultures from sterile sites. Secondary outcomes included 30-day readmission and 30-day mortality. The control population was patients with negative MRSA/MSSA nasal screening in the same hospital units. Results: In total, 4,465 (23%) of 19,065 screening tests were positive for MSSA (75%) or MRSA (25%). The median age was 69 years (IQR, 56–80), and the median length of stay (LOS) was 6 days (IQR, 4–10). Among patients with LOS ≥3 days, 541 (16%) completed decolonization and 2,161 (64%) received no decolonization. The rate of complete decolonization increased to 35% among those with LOS ≥ 7 days. In total, 802 screened patients developed invasive S. aureus infections. Of 4,437 colonized patients, 536 (12%) had invasive infections, compared with 265 (2.1%) invasive infections in 12,917 noncolonized patients. Among patients with S. aureus colonization, 24% of decolonized patients developed invasive infection and 13% of patients who were not decolonized developed invasive infection. Rates of 30-day readmission and mortality were 28% and 10%, respectively, among fully decolonized patients, versus 20% and 6.6% among those receiving no decolonization. Conclusions: These data provide an assessment of the efficacy of a targeted screening and decolonization program. Although decolonization did not reduce rates of invasive infection or secondary outcomes, further analysis is needed. Patients with longer lengths of stay are more likely to receive full decolonization but are also at higher risk of invasive infection, which may contribute to our unexpected results.
Funding: None
Disclosures: None
Moving Beyond Contact Precautions: Implementation of a Staphylococcus aureus Screening and Decolonization Program
- Sarah Hochman, Anna Stachel, Michael Phillips, Stephanie Sterling, Jennifer Lighter, Maria Aguero-Rosenfeld, Tamara King-Morrieson
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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. s321-s322
- Print publication:
- October 2020
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Background:Staphylococcus aureus–colonized hospitalized patients are at risk for invasive infection and can transmit S. aureus to other patients in the absence of symptoms. Infection isolation precautions do not reduce the risk of infection in colonized patients and are untenable in health systems with high rates of S. aureus colonization. Objective: We implemented an inpatient S. aureus screening and targeted decolonization program across hospital campuses to reduce transmission and invasive infection. We screen and decolonize for methicillin-susceptible S. aureus (MSSA) and methicillin-resistant S. aureus (MRSA) because MSSA makes up more than half of all S. aureus isolated from clinical cultures in our health system. Methods: All medicine, pediatrics, and transplant patients receive S. aureus nares culture at admission and upon change in level of care for medicine, and at admission and weekly for pediatrics and transplant patients. All S. aureus–colonized patients receive decolonization with nasal mupirocin ointment and chlorhexidine baths. Two implementation frameworks guide our processes for S. aureus screening and decolonization: the Consolidated Framework for Implementation Research, to evaluate factors affecting implementation at different levels of the health system, and the Dynamic Sustainability Framework, to account for iterative changes as the hospital setting and patient population change over time. Implementation interventions focus on education of patients and bedside nurses who perform S. aureus screening and decolonization; utilization of the electronic health record to identify patients for screening and/or decolonization and avoid human error; and introduction of a clinical nurse specialist to oversee the program and to provide iterative feedback. Results: At baseline, 21% of patients had S. aureus colonization, 20% of which was MRSA, and the MRSA bloodstream infection rate was 0.06 per 1,000 patient days. After program implementation, there was no change in S. aureus colonization and the MRSA bloodstream infection rate fell to 0.04 per 1,000 patient days. Screening compliance improved from 39% (N = 1,805) of eligible patients in the 6-month period before the introduction of the clinical nurse specialist to 52% (N = 2,024) after the introduction of the clinical nurse specialist. In the same periods, decolonization increased from 18.6% to 41% of eligible patients. Conclusions: We used 2 implementation frameworks to design our S. aureus screening and decolonization program and to make iterative changes to the program as it evolved to include new patient populations and different hospital settings. This resulted in a large-scale, sustainable, health system program for S. aureus control that avoids reliance on infection isolation precautions.
Funding: None
Disclosures: None
Implementing an Automated Pneumonia Surveillance System
- Dan Ding, Michael Phillips, Eduardo Iturrate, Sarah Hochman, Anna Stachel
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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. s281-s283
- Print publication:
- October 2020
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Background: Although definitions from the CDC were developed to increase the reliability of surveillance data, reduce the burden of surveillance in healthcare facilities, and enhance the utility of surveillance data for improving patient safety, the algorithm is still laborious for manual use. We implemented an automated surveillance system that combines 2 CDC pneumonia surveillance definitions to identify pneumonia infection in inpatients. Methods: The program was implemented at an academic health center with >40,000 inpatient admission per year. We used Window Task Scheduler with a batch file daily to run a validated pneumonia surveillance algorithm program written with SAS version 9.4 software (SAS Institute, Cary, NC) and a natural language processing tool that queries variables (Table 1) and text found in the electronic medical records (EMR) to identify pneumonia cases (Fig. 1). We uploaded all computer-identified positive cases into a Microsoft Access database daily to be reviewed by a hospital epidemiologist. Every week, we also validated 5 computer-identified negative cases from the prior 2 weeks to ensure accuracy of the computer algorithm. We defined negative cases as pneumonia present on admission or chest x-ray indicative of pneumonia but without CDC-defined surveillance symptoms. We also wrote a program to automatically send e-mails to key stakeholders and to prepare summary reports. Results: Since November 2019, we have successfully implemented the automated computer algorithm or program to notify, via e-mail, infection prevention staff and respiratory therapy providers of CDC-defined pneumonia cases on a daily basis. This automated program has reduced the number of manual hours spent reviewing each admission case for pneumonia. A summary report is created each week and month for distribution to hospital staff and the Department of Health, respectively. Conclusions: The implementation of an automated pneumonia surveillance system proves to be a timelier, more cost-effective approach compared to manual pneumonia surveillance. By allowing an automated algorithm to review pneumonia, timely reports can be sent to infection prevention control staff, respiratory therapy providers, and unit staff about individual cases. Hospitals should leverage current technology to automate surveillance definitions because automated programs allow near real-time identification and critical review for infection and prevention activities.
Funding: None
Disclosures: None
Use of Varying Single-Nucleotide Polymorphism Thresholds to Identify Strong Epidemiologic Links Among Patients with Methicillin-Resistant Staphylococcus aureus (MRSA)
- Ioannis Zacharioudakis, Dan Ding, Fainareti Zervou, Anna Stachel, Sarah Hochman, Stephanie Sterling, Jennifer Lighter, Maria Aguero-Rosenfeld, Bo Shopsin, Michael Phillips
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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. s423-s424
- Print publication:
- October 2020
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Background: Whole-genome sequencing (WGS) has a high discriminatory power in confirming outbreaks. Outbreak investigation models that categorize the possibility of an outbreak based on the degree of genetic relatedness of isolates are highly dependent on the single-nucleotide polymorphism (SNP) threshold used. Methods: NYU Langone Medical center is a 725-bed academic center that has implemented WGS of methicillin-resistant Staphylococcus aureus (MRSA) isolates since 2016. Patients admitted to a medical or intensive care unit were screened on admission and transfer. The first surveillance and clinical MRSA isolate during each hospitalization was sequenced. We conducted a retrospective analysis to identify strong epidemiologic links among patients involved in genetically related clusters. We used different SNP thresholds to define genetic relatedness to identify the optimal threshold that should prompt an outbreak investigation. We considered strong hospital epidemiologic links sharing the same room or unit or having resided in the same room or unit within 7 days. A pairwise analysis was conducted to compare the epidemiologic links among patients involved in genetically related clusters. Results: Among 1,070 isolates, our analysis focused on 777 belonging to USA100 and USA300 clones. For USA100 isolates, we identified 8, 14, and 20 clusters comprising of 16, 29, and 42 patients when the threshold for genetic relatedness was set at 20, 40, and 60 SNP differences, respectively. Patients identified in a cluster yielded a strong hospital epidemiologic link in 62.5%, 87.5%, and 91.7% of cases (Fig. 1). For USA300 isolates, SNP differences of 10, 20, and 30 were used, identifying 20, 34, and 40 clusters of 43, 79, and 127 patients. The expansion of the threshold from 10 to 30 resulted in a decrease of the percentage of pairwise analyses with a strong hospital epidemiologic link from 57.7% to 13.6% by increasing 13-fold the number of analyses that were conducted to identify only 3 times more cases with strong epidemiologic links (Fig. 2). Conclusions: The results of our study indicate that SNPs thresholds determined by intrapatient variability of MRSA isolates might need to be tailored to the individual setting to guide infection control interventions because optimal thresholds might vary depending on characteristics of the population, MRSA isolates, and screening practices. Establishing conservative thresholds might allow the identification and quantification over time of the locations (eg, rooms or units) where transmission is occurring as well as the investigation of the clusters without strong epidemiologic links that might be valuable in elucidating unrecognized routes of transmission.
Funding: None
Disclosures: None