The Ethics of Disclosing Another Physician's Medical Error

The disclosure of medical errors has been shown to improve quality of care and decrease litigation and cost. However, much less attention has been given to how to manage situations in which a patient has been treated less than optimally at another institution or by another physician. The same ethical principles that support disclosing one's own errors apply to disclosure of other people's errors. Disclosing errors and encouraging quality improvement at other institutions or by other providers must be performed in a sensitive and judicious manner.

Management of patients with advanced prostate cancer: recommendations of the St Gallen Advanced Prostate Cancer Consensus Conference (APCCC) 2015

The first St Gallen Advanced Prostate Cancer Consensus Conference (APCCC) Expert Panel identified and reviewed the available evidence for the ten most important areas of controversy in advanced prostate cancer (APC) management. The successful registration of several drugs for castration-resistant prostate cancer and the recent studies of chemo-hormonal therapy in men with castration-naïve prostate cancer have led to considerable uncertainty as to the best treatment choices, sequence of treatment options and appropriate patient selection. Management recommendations based on expert opinion, and not based on a critical review of the available evidence, are presented. The various recommendations carried differing degrees of support, as reflected in the wording of the article text and in the detailed voting results recorded in supplementary Material, available at Annals of Oncology online. Detailed decisions on treatment as always will involve consideration of disease extent and location, prior treatments, host factors, patient preferences as well as logistical and economic constraints. Inclusion of men with APC in clinical trials should be encouraged.

Use of Gloves and Reduction of Risk of Injury Caused by Needles or Sharp Medical Devices in Healthcare Workers: Results from a Case-Crossover Study

Objective.

Standard precautions are advocated for reducing the number of injuries caused by needles and sharp medical devices (“sharps injuries”), but the effectiveness of gloves in preventing such injuries has not been established. We evaluated factors associated with gloving practices and identified associations between gloving practices and sharps-injury risk.

Design.

Usual-frequency case-crossover study.

Setting.

Thirteen medical centers in the United States and Canada.

Participants.

Six hundred thirty-six healthcare workers who presented to employee health clinics after sharps injury.

Methods.

Structured telephone questionnaires were administered to assess usual behaviors and circumstances at the time of injury.

Results.

Of 636 injured healthcare workers, 195 were scrubbed in an operating room or procedure suite when injured, and 441 were injured elsewhere. Nonscrubbed individuals were more commonly gloved when treating patients who were perceived to have a high risk of human immunodeficiency virus, hepatitis B virus, or hepatitis C virus infection than when treating other patients (adjusted odds ratio [aOR], 2.53 [95% confidence interval {CI}, 1.30-4.91]). Nurses (aOR, 0.11 [95% CI, 0.04-0.32]) and other employees (aOR, 0.24 [95% CI, 0.07-0.77]) were less commonly gloved at injury than were physicians and physician trainees. Gloves reduced injury risk in case-crossover analyses (incidence rate ratio [IRR], 0.33 [95% CI, 0.22-0.50]). In scrubbed individuals, involvement in an orthopedic procedure was associated with double gloving at injury (aOR, 13.7 [95% CI, 4.55-41.3]); this gloving practice was associated with decreased injury risk (IRR, 0.20 [95% CI, 0.10-0.42]).

Conclusions.

Although the use of gloves reduces the risk of sharps injuries in health care, use among healthcare workers is inconsistent and may be influenced by risk perception and healthcare culture. Glove use should be emphasized as a key element of multimodal sharps-injury reduction programs.

Health care-associated methicillin-resistant Staphylococcus aureus infections increases the risk of postdischarge mortality

BACKGROUND

Although many studies have estimated the impact of health care-associated methicillin-resistant Staphylococcus aureus (MRSA) infections on mortality during initial hospitalization, little is known about the long-term risk of death in these patients. The purpose of this study was to quantify the effect of MRSA health care-acquired infections (HAIs) on mortality after hospital discharge.

METHODS

Our study cohort consisted of patients with inpatient admission within the U.S. Department of Veterans Affairs system between October 1, 2007, and September 30, 2010. Of these patients, we identified those with a positive MRSA culture from electronic microbiology reports. We constructed multivariable Cox proportional hazards regressions to assess the impact of a positive culture on postdischarge mortality in the 365 days following discharge using both the full cohort and a propensity score-matched subsample.

RESULTS

In our analysis cohort of 369,743 inpatients, positive MRSA cultures were recorded in 3,599 (1.0%) patients. We found that positive cultures resulted in an increased risk of postdischarge mortality both in the full cohort (hazard ratio = 1.42, P < .001) and in the subset of propensity score-matched patients (hazard ratio = 1.37, P < .0001).

CONCLUSION

We found that MRSA HAIs significantly elevate the long-term risk of mortality. These results underscore the importance of infection prevention efforts in the hospital.

Initiation and termination of antibiotic regimens in Veterans Affairs hospitals

OBJECTIVES

To assess rates of starting or stopping antibiotics across different hospitals.

METHODS

We used barcode medication administration data to measure antibiotic use on acute-care wards in 128 Veterans Affairs medical centres (VAMCs) in 2010. A treatment day (TD) was defined as the administration of any antibiotic on a given day. A treatment period (TP) was defined as an interval of inpatient antimicrobial therapy with gaps of ≤1 day in TDs. The rate of starting antibiotics was calculated for inpatients who had not yet started antibiotics, as the number of start events divided by the 'person-time at risk'. The rate of stopping antibiotics was calculated analogously for inpatients that were on antibiotics. Once individuals had stopped antibiotics they were removed from further analysis. Per-day start and stop rates were also calculated for each day of hospitalization.

RESULTS

The hospital mean rate of starting the first TP was 18.1 start events/100 days at risk (range 8.4-25.6/100 days at risk). The mean hospital stopping rate was 21.1 stop events/100 days at risk (range 13.3-29.5/100 days at risk). The ratio of a facility's starting and stopping rates was highly correlated with overall antibiotic use in TDs/1000 patient-days (rs=0.92, P<0.001), while starting and stopping rates individually were only moderately correlated (rs=0.39, P<0.001).

CONCLUSIONS

VAMCs with similar antibiotic use showed marked differences in their starting and stopping rates of antibiotics. It may be useful to target empirical therapy when starting rates are high and definitive therapy when stopping rates are low.

Does universal active MRSA surveillance influence anti-MRSA antibiotic use? A retrospective analysis of the treatment of patients admitted with suspicion of infection at Veterans Affairs Medical Centers between 2005 and 2010

OBJECTIVES

After the implementation of an active surveillance programme for MRSA in US Veterans Affairs (VA) Medical Centers, there was an increase in vancomycin use. We investigated whether positive MRSA admission surveillance tests were associated with MRSA-positive clinical admission cultures and whether the availability of surveillance tests influenced prescribers' ability to match initial anti-MRSA antibiotic use with anticipated MRSA results from clinical admission cultures.

METHODS

Analyses were based on barcode medication administration data, microbiology data and laboratory data from 129 hospitals between January 2005 and September 2010. Hospitalized patient admissions were included if clinical cultures were obtained and antibiotics started within 2 days of admission. Mixed-effects logistic regression was used to examine associations between positive MRSA admission cultures and (i) admission MRSA surveillance test results and (ii) initial anti-MRSA therapy.

RESULTS

Among 569,815 included admissions, positive MRSA surveillance tests were strong predictors of MRSA-positive admission cultures (OR 8.5; 95% CI 8.2-8.8). The negative predictive value of MRSA surveillance tests was 97.6% (95% CI 97.5%-97.6%). The diagnostic OR between initial anti-MRSA antibiotics and MRSA-positive admission cultures was 3.2 (95% CI 3.1-3.4) for patients without surveillance tests and was not significantly different for admissions with surveillance tests.

CONCLUSIONS

The availability of nasal MRSA surveillance tests in VA hospitals did not seem to improve the ability of prescribers to predict the necessity of initial anti-MRSA treatment despite the high negative predictive value of MRSA surveillance tests. Prospective trials are needed to establish the safety and effectiveness of using MRSA surveillance tests to guide antibiotic therapy.

Vital signs: improving antibiotic use among hospitalized patients

BACKGROUND

Antibiotics are essential to effectively treat many hospitalized patients. However, when antibiotics are prescribed incorrectly, they offer little benefit to patients and potentially expose them to risks for complications, including Clostridium difficile infection (CDI) and antibiotic-resistant infections. Information is needed on the frequency of incorrect prescribing in hospitals and how improved prescribing will benefit patients.

METHODS

A national administrative database (MarketScan Hospital Drug Database) and CDC's Emerging Infections Program (EIP) data were analyzed to assess the potential for improvement of inpatient antibiotic prescribing. Variability in days of therapy for selected antibiotics reported to the National Healthcare Safety Network (NHSN) antimicrobial use option was computed. The impact of reducing inpatient antibiotic exposure on incidence of CDI was modeled using data from two U.S. hospitals.

RESULTS

In 2010, 55.7% of patients discharged from 323 hospitals received antibiotics during their hospitalization. EIP reviewed patients' records from 183 hospitals to describe inpatient antibiotic use; antibiotic prescribing potentially could be improved in 37.2% of the most common prescription scenarios reviewed. There were threefold differences in usage rates among 26 medical/surgical wards reporting to NHSN. Models estimate that the total direct and indirect effects from a 30% reduction in use of broad-spectrum antibiotics will result in a 26% reduction in CDI.

CONCLUSIONS

Antibiotic prescribing for inpatients is common, and there is ample opportunity to improve use and patient safety by reducing incorrect antibiotic prescribing. Implications for Public Health: Hospital administrators and health-care providers can reduce potential harm and risk for antibiotic resistance by implementing formal programs to improve antibiotic prescribing in hospitals.

A simulation-based assessment of strategies to control Clostridium difficile transmission and infection

Background

Clostridium difficile is one of the most common and important nosocomial pathogens, causing severe gastrointestinal disease in hospitalized patients. Although "bundled" interventions have been proposed and promoted, optimal control strategies remain unknown.

Methods

We designed an agent-based computer simulation of nosocomial C. difficile transmission and infection, which included components such as: patients and health care workers, and their interactions; room contamination via C. difficile shedding; C. difficile hand carriage and removal via hand hygiene; patient acquisition of C. difficile via contact with contaminated rooms or health care workers; and patient antimicrobial use. We then introduced six interventions, alone and "bundled" together: aggressive C. difficile testing; empiric isolation and treatment of symptomatic patients; improved adherence to hand hygiene and contact precautions; improved use of soap and water for hand hygiene; and improved environmental cleaning. All interventions were tested using values representing base-case, typical intervention, and optimal intervention scenarios.

Findings

In the base-case scenario, C. difficile infection rates ranged from 8–21 cases/10,000 patient-days, with a case detection fraction between 32%–50%. Implementing the "bundle" at typical intervention levels had a large impact on C. difficile acquisition and infection rates, although intensifying the intervention to optimal levels had much less additional impact. Most of the impact came from improved hand hygiene and empiric isolation and treatment of suspected C. difficile cases.

Conclusion

A "bundled" intervention is likely to reduce nosocomial C. difficile infection rates, even under typical implementation conditions. Real-world implementation of the "bundle" should focus on those components of the intervention that are likely to produce the greatest impact on C. difficile infection rates, such as hand hygiene and empiric isolation and treatment of suspected cases.

Racial differences in withdrawal of mechanical ventilation do not alter mortality in neurologically injured patients

PURPOSE

Racial differences in withdrawal of mechanical ventilation (WMV) have been demonstrated among patients with severe neurologic injuries. We ascertained whether such differences might be accounted for by imbalances in socioeconomic status or disease severity, and whether such racial differences impact hospital mortality or result in greater discharge to long-term care facilities.

MATERIALS AND METHODS

We evaluated WMV among 1885 mechanically ventilated patients with severe neurologic injury (defined as Glasgow Coma Scale <9), excluding those progressing to brain death within the first 48 hours.

RESULTS

Withdrawal of mechanical ventilation was less likely in nonwhite patients (22% vs 31%, P < .001). Nonwhites were younger and were more likely to have Medicaid or no insurance, live in ZIP codes with low median household incomes, be unmarried, and have greater illness severity; but after adjustment for these variables, racial difference in WMV persisted (odds ratio, 0.56; 95% confidence interval, 0.42-0.76). Nonwhite patients were more likely to die instead with full support or progress to brain death, resulting in equivalent overall hospital mortality (40% vs 42%, P = .44). Among survivors, nonwhites were more likely to be discharged to long-term care facilities (27% vs 17%, P < .001).

CONCLUSIONS

Surrogates of nonwhite neurologically injured patients chose WMV less often even after correcting for socioeconomic status and other confounders. This difference in end-of-life decision making does not appear to alter hospital mortality but may result in more survivors left in a disabled state.

Relationships between the importation, transmission, and nosocomial infections of methicillin-resistant Staphylococcus aureus: an observational study of 112 Veterans Affairs Medical Centers

BACKGROUND

The study of hospital methicillin-resistant Staphylococcus aureus (MRSA) epidemiology is complicated by its transmissibility. Our objective was to understand how MRSA importation and transmission influence MRSA nosocomial infections in Veterans Affairs Medical Centers (VAMCs).

METHODS

We performed hospital-level analyses of acute-care MRSA admission prevalence, acquisition rates, and incident nosocomial clinical culture (INCC) rates, each a surrogate measure of importation, transmission, and nosocomial infection, respectively. We studied 112 VAMCs from October 2007 through September 2010, after the start of a bundled intervention including active surveillance for MRSA. We analyzed data using generalized linear mixed models.

RESULTS

A total of 2.9 million surveillance tests were collected from 1.4 million patient admissions. Overall MRSA admission prevalence was 11.4%, acquisition was 5.2 per 1000 patient-days at risk, and INCC was 1.8 per 1000 patient-days at risk. A 10% increase in a hospital's average admission prevalence was associated with a 9.7% increase in its weekly acquisition rates (P < .001) and a 9.8% increase in its weekly INCC rates (P < .001). Significant decreases were observed in all 3 measures during the study period (P < .001). When INCC rates were stratified by nasal MRSA carriage at admission, a significant downward trend was observed only among those initially negative.

CONCLUSIONS

Measured associations between MRSA admission prevalence, acquisition rate, and INCC rate were consistent with the hypothesis that decreased acquisition led to decreased importation, which in turn further abated acquisition. The downward trend in INCC rate specifically among individuals with negative admission surveillance tests suggests that decreasing transmission contributed to lower rates of nosocomial MRSA infection.

Distinct ERG rearrangement prevalence in prostate cancer: higher frequency in young age and in low PSA prostate cancer

Background:

The TMPRSS2-ERG gene fusion resulting in ERG overexpression has been found in around 50% of prostate cancers (PCa) and is a very early event in tumorigenesis. Most studies have reported on selected surgical cohorts with inconsistent results. We hypothesized that ERG gene rearrangements impact tumor development and investigated the frequency of ERG overexpression in the context of clinicopathological tumor characteristics.

Methods:

ERG overexpression (ERG+ or ERG-) was determined by immunohistochemistry (IHC) in 1039 radical prostatectomy (RP) tumors and association with PSA, D'Amico risk score, histopathology, biochemical recurrence, body mass index and age of PCa cases was analyzed.

Results:

ERG+ was associated with younger age at diagnosis (P<0.0001), lower serum PSA (P=0.002) and lower prostate volume (PV) (P=0.001). It was most frequent in the youngest age quartile (⩽55 years, 63.9% ERG+) and decreased constantly with increasing age to 40.8% in the oldest age quartile (⩾67 years, P<0.0001). In the PSA range <4 ng ml⁻¹ the frequency of ERG positivity was 60.2% compared with 47.5 and 49.1% in the PSA ranges 4–10 and ⩾10 ng ml⁻¹, respectively. In the first age quartile, ERG+ patients had lower median serum PSA and fPSA% and smaller PV. In the highest age quartile tumor volume (TV) was increased. Similar differences were observed in the low PSA range. Multivariate analysis identified the first age quartile as a predictor for ERG status (odds ratios (OR) 2.05, P=0.007). No association was found with the D'Amico progression risk score and with biochemical tumor recurrence.

Conclusions:

ERG+ tumors manifest clinically at lower PSA levels and their prevalence is age dependent. This suggests acceleration of tumor development by ERG overexpression that results in earlier tumor detection in young patients. Long-term results are warranted to determine the impact of ERG overexpression on disease outcome.

Maternal serum progesterone, estradiol and estriol levels in successful dinoprostone-induced labor

Hormone-mediated quiescence involves the maintenance of a decreased inflammatory responsiveness. However, no study has investigated whether labor induction with prostanoids is associated with changes in the levels of maternal serum hormones. The objective of this study was to determine whether labor induction with dinoprostone is associated with changes in maternal serum progesterone, estradiol, and estriol levels. Blood samples were obtained from 81 pregnant women at term. Sixteen patients had vaginal birth after spontaneous labor, 12 required cesarean section after spontaneous labor and 16 underwent elective cesarean. Thirty-seven patients had labor induction with dinoprostone. Eligible patients received a vaginal insert of dinoprostone (10 mg) and were followed until delivery. Serum progesterone (P4), estradiol (E2) and estriol (E3) levels and changes in P4/E2, P4/E3 and E3/E2 ratios were monitored from admission to immediately before birth, and the association of these measures with the resulting clinical classification outcome (route of delivery and induction responsiveness) was assessed. Progesterone levels decreased from admission to birth in patients who underwent successful labor induction with dinoprostone [vaginal and cesarean birth after induced labor: 23% (P < 0.001) and 18% (P < 0.025) decrease, respectively], but not in those whose induction failed (6.4% decrease, P > 0.05). Estriol and estradiol levels, P4/E2, P4/E3 and E3/E2 ratios did not differ between groups. Successful dinoprostone-induced labor was associated with reduced maternal progesterone levels from induction to birth. While a causal relationship between progesterone decrease and effective dinoprostone-induced labor cannot be established, it is tempting to propose that dinoprostone may contribute to progesterone withdrawal and favor labor induction in humans.

Decolonization with Mupirocin and Subsequent Risk of Methicillin-Resistant Staphylococcus aureus Carriage in Veterans Affairs Hospitals

Introduction

Hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA) infections remain one of the leading causes of preventable patient mortality in the US. Eradication of MRSA through decolonization could prevent both MRSA infections and transmission; however, there is currently no consensus within the infectious disease community on the proper role of decolonization in the prevention of infections. The purpose of this study was to assess the impact of decolonization with mupirocin on subsequent MRSA carriage.

Methods

Patients included in this study were those with an inpatient admission to a Department of Veterans Affairs (VA) hospital between January 1, 2008 and December 31, 2009 who had a positive MRSA screen on admission and a subsequent re-admission during the same time period. Exposure to mupirocin on the initial hospital admission was measured using Barcode Medication Administration data and MRSA carriage was measured using microbiology text reports and lab data containing results from surveillance swabs collected from the nares. Chi-square tests were used to test for differences in re-admission MRSA carriage rates between mupirocin-receiving and non-mupirocin-receiving patients.

Results

Of the 25,282 MRSA-positive patients with a subsequent re-admission included in the present study cohort, 1,183 (4.7%) received mupirocin during their initial hospitalization. Among the patients in the present study cohort who were re-admitted within 30 days, those who received mupirocin were less likely to test positive for MRSA carriage than those who did not receive mupirocin (27.2% vs. 55.1%, P < 0.001). The proportion of those who tested positive for MRSA during re-admissions that occurred 30–60 days, 60–120 days, and >120 days were 33.9, 37.3, and 41.0%, respectively, among mupirocin patients and 52.7%, 53.0%, and 51.9%, respectively, for patients who did not receive mupirocin (P < 0.001 at each time point).

Conclusion

Patients decolonized with mupirocin in VA hospitals were less likely to be colonized with MRSA on re-admission as long as 4 months after decolonization.

Evaluation of 2009 pandemic influenza A (H1N1) exposures and illness among physicians in training

BACKGROUND

A cluster of influenza-like illness (ILI) among physicians in training during the 2009 influenza A (H1N1) pandemic (pH1N1) led to a health hazard evaluation.

METHODS

We conducted a cross-sectional study to examine exposures, infection control practices, ILI prevalence, and transmission among physicians in training at 4 affiliated hospitals during the pandemic. We administered an electronic survey and met with physicians in training and hospital personnel.

RESULTS

Of the 88 responding physicians, 85% reported exposure to pH1N1. Exposures occurred at work from patients or coworkers and outside of work from coworkers, household members, or the community. Thirteen cases of ILI were reported in May-June 2009; 10 respondents reported working while ill (duration, 1-4 days). Between 13% and 88% of respondents knew which personal protective equipment (PPE) was recommended when caring for influenza patients at the 4 hospitals. The most common reasons for not using PPE were not knowing that a patient had pH1N1 or ILI and not having PPE readily available.

CONCLUSIONS

Physicians in training have gaps in their knowledge of and adherence to recommended PPE and compliance with work restrictions. Our findings underscore the importance of installing isolation precaution signage, making PPE readily available near patients with influenza, and facilitating work restrictions for ill health care personnel.

Involvement of the glutamatergic system in the nociception induced intrathecally for a TRPA1 agonist in rats

The transient receptor potential ankyrin 1 (TRPA1) is expressed in peripheral and spinal terminals of sensory neurons, jointly to the vanilloid receptor (TRPV1). A relevant peripheral role of TRPA1 receptor has been implicated in a variety of processes, including the detection of noxious cold, and diverse painful stimulus, but the functional role of TRPA1 receptor in nociceptive transmission at spinal cord in vivo is poorly known. Therefore, the aim of this study was to evaluate whether the glutamatergic system is involved in the transmission of nociceptive stimulus induced for a TRPA1 agonist in the rat spinal cord. We observed that cinnamaldehyde, a TRPA1 agonist, on spinal cord synaptosomes leads to an increase in [Ca(2+)](i) and a rapid release of glutamate, but was not able to change the specific [(3)H]-glutamate binding. In addition, spinally administered cinnamaldehyde produced heat hyperalgesia and mechanical allodynia in rats. This behavior was reduced by the co-injection (i.t.) of camphor (TRPA1 antagonist) or MK-801 (N-methyl-D-aspartate (NMDA) receptor antagonist) to cinnamaldehyde. Besides, the pretreatment with resiniferatoxin (RTX), a potent TRPV1 agonist, abolished the cinnamaldehyde-induced heat hyperalgesia. Here, we showed that intrathecal RTX results in a decrease in TRPA1 and TRPV1 immunoreactivity in dorsal root ganglion. Collectively, our results demonstrate the pertinent participation of spinal TRPA1 in the possible enhancement of glutamatergic transmission of nociceptive signals leading to increase of the hypersensitivity, here observed as heat hyperalgesia. Then the modulation of spinal TRPA1 might be a valuable target in painful conditions associated with central pain hypersensitivity.

Parenteral to oral conversion of fluoroquinolones: low-hanging fruit for antimicrobial stewardship programs?

OBJECTIVE

To estimate avoidable intravenous (IV) fluoroquinolone use in Veterans Affairs (VA) hospitals.

DESIGN

A retrospective analysis of bar code medication administration (BCMA) data.

SETTING

Acute care wards of 128 VA hospitals throughout the United States.

METHODS

Data were analyzed for all medications administered on acute care wards between January 1, 2006, and December 31, 2010. Patient-days receiving therapy were expressed as fluoroquinolone-days (FD) and divided into intravenous (IV; all doses administered intravenously) and oral (PO; at least one dose administered per os) FD. We assumed IV fluoroquinolone use to be potentially avoidable on a given IV FD when there was at least 1 other medication administered via the enteral route.

RESULTS

Over the entire study period, 884,740 IV and 830,572 PO FD were administered. Overall, avoidable IV fluoroquinolone use accounted for 46.8% of all FD and 90.9% of IV FD. Excluding the first 2 days of all IV fluoroquinolone courses and limiting the analysis to the non-ICU setting yielded more conservative estimates of avoidable IV use: 20.9% of all FD and 45.9% of IV FD. Avoidable IV use was more common for levofloxacin and more frequent in the ICU setting. There was a moderate correlation between avoidable IV FD and total systemic antibiotic use (r = 0.32).

CONCLUSIONS

Unnecessary IV fluoroquinolone use seems to be common in the VA system, but important variations exist between facilities. Antibiotic stewardship programs could focus on this patient safety issue as a "low-hanging fruit" to increase awareness of appropriate antibiotic use.

Long-term care facilities in Utah: a description of human and information technology resources applied to infection control practice

BACKGROUND

Little is known about the implementation of infection control (IC) programs and information technology (IT) infrastructure in long-term care facilities (LTCFs). We assessed the IC human resources, IT infrastructure, and IC scope of practice at LTCFs in Utah.

METHODS

All LTCFs throughout Utah (n = 80) were invited to complete a written survey in 2005 regarding IC staffing, policies and practices, and IT infrastructure and capacity.

RESULTS

Responses were received from 62 facilities (77.5%). Most infection preventionists (IPs) were registered nurses (71%) with on-the-job training (81.7%). Most had other duties besides their IC work (93.5%), which took up the majority of their time. Most facilities provided desktop computers (96.8%) and all provided Internet access, but some of the infrastructure was not current. A minority (14.5%) used sophisticated software packages to support their IC activities. Less than 20% of the facilities had integrated radiology, diagnostic laboratory, or microbiology data with their facility computer system. The Internet was used primarily as a reference tool (77.4%). Most IPs reported taking responsibility for routine surveillance and monitoring tasks, but a substantial number did not perform all queried tasks. They may have difficulty with feedback of specific unit and physician infection rates (43.2% and 67.7%, respectively).

CONCLUSIONS

Our findings underscore what has previously been reported about LTCFs' IC human resources and IP scope of practice. We also found that some IT infrastructure was outdated, and that existing resources were underutilized for IC purposes.

Drugs of last resort? The use of polymyxins and tigecycline at US Veterans Affairs medical centers, 2005-2010

Multidrug-resistant (MDR) and carbapenem-resistant (CR) Gram-negative pathogens are becoming increasingly prevalent around the globe. Polymyxins and tigecycline are among the few antibiotics available to treat infections with these bacteria but little is known about the frequency of their use. We therefore aimed to estimate the parenteral use of these two drugs in Veterans Affairs medical centers (VAMCs) and to describe the pathogens associated with their administration. For this purpose we retrospectively analyzed barcode medication administration data of parenteral administrations of polymyxins and tigecycline in 127 acute-care VAMCs between October 2005 and September 2010. Overall, polymyxin and tigecycline use were relatively low at 0.8 days of therapy (DOT)/1000 patient days (PD) and 1.6 DOT/1000PD, respectively. Use varied widely across facilities, but increased overall during the study period. Eight facilities accounted for three-quarters of all polymyxin use. The same statistic for tigecycline use was twenty-six VAMCs. There were 1,081 MDR or CR isolates during 747 hospitalizations associated with polymyxin use (1.4/hospitalization). For tigecycline these number were slightly lower: 671 MDR or CR isolates during 500 hospitalizations (1.3/hospitalization) (p = 0.06). An ecological correlation between the two antibiotics and combined CR and MDR Gram-negative isolates per 1000PD during the study period was also observed (Pearson’s correlation coefficient r = 0.55 polymyxin, r = 0.19 tigecycline). In summary, while polymyxin and tigecycline use is low in most VAMCs, there has been an increase over the study period. Polymyxin use in particular is associated with the presence of MDR Gram-negative pathogens and may be useful as a surveillance measure in the future.

Prediction of potential for organ donation after cardiac death in patients in neurocritical state: a prospective observational study

BACKGROUND

Successful donation of organs after cardiac death (DCD) requires identification of patients who will die within 60 min of withdrawal of life-sustaining treatment (WLST). We aimed to validate a straightforward model to predict the likelihood of death within 60 min of WLST in patients with irreversible brain injury.

METHODS

In this multicentre, observational study, we prospectively enrolled consecutive comatose patients with irreversible brain injury undergoing WLST at six medical centres in the USA and the Netherlands. We assessed four clinical characteristics (corneal reflex, cough reflex, best motor response, and oxygenation index) as predictor variables, which were selected on the basis of previous findings. We excluded patients who had brain death or were not intubated. The primary endpoint was death within 60 min of WLST. We used univariate and multivariable logistic regression analyses to assess associations with predictor variables. Points attributed to each variable were summed to create a predictive score for cardiac death in patients in neurocritical state (the DCD-N score). We assessed performance of the score using area under the curve analysis.

FINDINGS

We included 178 patients, 82 (46%) of whom died within 60 min of WLST. Absent corneal reflexes (odds ratio [OR] 2·67, 95% CI 1·19-6·01; p=0·0173; 1 point), absent cough reflex (4·16, 1·79-9·70; p=0·0009; 2 points), extensor or absent motor responses (2·99, 1·22-7·34; p=0·0168; 1 point), and an oxygenation index score of more than 3·0 (2·31, 1·10-4·88; p=0·0276; 1 point) were predictive of death within 60 min of WLST. 59 of 82 patients who died within 60 min of WLST had DCD-N scores of 3 or more (72% sensitivity), and 75 of 96 of those who did not die within this interval had scores of 0-2 (78% specificity); taking into account the prevalence of death within 60 min in this population, a score of 3 or more was translated into a 74% chance of death within 60 min (positive predictive value) and a score of 0-2 translated into a 77% chance of survival beyond 60 min (negative predictive value).

INTERPRETATION

The DCD-N score can be used to predict potential candidates for DCD in patients with non-survivable brain injury. However, this score needs to be tested specifically in a cohort of potential donors participating in DCD protocols.

FUNDING

None.

Double trouble: how big a problem is redundant anaerobic antibiotic coverage in Veterans Affairs medical centres?

OBJECTIVES

To assess the prevalence of, and the variation in, avoidable use of metronidazole in the Veterans Affairs (VA) healthcare system

METHODS

Barcode Medication Administration (BCMA) data were retrospectively assessed for all patients hospitalized between January 2006 and December 2010 in acute-care wards of all VA medical centres (VAMCs) with complete BCMA data and at least 10 acute-care non-intensive care unit (ICU) beds. Potentially avoidable metronidazole days of therapy (DOT) were defined as the administration of metronidazole with another anti-anaerobic antibiotic on the same day for at least two consecutive days during the same hospitalization. Metronidazole was not considered redundant in combination with another anti-anaerobic agent within 28 days after a positive test for Clostridium difficile and during hospitalizations associated with discharge diagnosis codes for cholecystitis or cholangitis.

RESULTS

A total of 128 VAMCs satisfied the inclusion criteria. Over the study period there were a total of 782,821 DOT of metronidazole (57.4 DOT per 1000 patient-days), of which 183,267 (23.4%) fulfilled the criteria for avoidable metronidazole DOT. The percentage of avoidable metronidazole DOT remained stable over the study period (22.8% in 2006 and 22.9% in 2010) despite a decrease in overall metronidazole use. There was wide variation in the percentage of avoidable metronidazole DOT among facilities (2010: median 20.3%, IQR 15.3%-29.4%). Piperacillin/tazobactam was the most commonly administered drug on avoidable metronidazole DOT (56.8%).

CONCLUSIONS

Potentially avoidable use of metronidazole affected about a quarter of all days when metronidazole was given. The combination of metronidazole with piperacillin/tazobactam was particularly common and represents a possible target for antibiotic stewardship interventions.

Validity of ICD-9-CM coding for identifying incident methicillin-resistant Staphylococcus aureus (MRSA) infections: is MRSA infection coded as a chronic disease?

BACKGROUND AND OBJECTIVE

Investigators and medical decision makers frequently rely on administrative databases to assess methicillin-resistant Staphylococcus aureus (MRSA) infection rates and outcomes. The validity of this approach remains unclear. We sought to assess the validity of the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) code for infection with drug-resistant microorganisms (V09) for identifying culture-proven MRSA infection.

DESIGN

Retrospective cohort study.

METHODS

All adults admitted to 3 geographically distinct hospitals between January 1, 2001, and December 31, 2007, were assessed for presence of incident MRSA infection, defined as an MRSA-positive clinical culture obtained during the index hospitalization, and presence of the V09 ICD-9-CM code. The κ statistic was calculated to measure the agreement between presence of MRSA infection and assignment of the V09 code. Sensitivities, specificities, positive predictive values, and negative predictive values were calculated.

RESULTS

There were 466,819 patients discharged during the study period. Of the 4,506 discharged patients (1.0%) who had the V09 code assigned, 31% had an incident MRSA infection, 20% had prior history of MRSA colonization or infection but did not have an incident MRSA infection, and 49% had no record of MRSA infection during the index hospitalization or the previous hospitalization. The V09 code identified MRSA infection with a sensitivity of 24% (range, 21%-34%) and positive predictive value of 31% (range, 22%-53%). The agreement between assignment of the V09 code and presence of MRSA infection had a κ coefficient of 0.26 (95% confidence interval, 0.25-0.27).

CONCLUSIONS

In its current state, the ICD-9-CM code V09 is not an accurate predictor of MRSA infection and should not be used to measure rates of MRSA infection.