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Quarton S, Livesey A, Pittaway H, Adiga A, Grudzinska F, McNally A, Dosanjh D, Sapey E, Parekh D. Clinical challenge of diagnosing non-ventilator hospital-acquired pneumonia and identifying causative pathogens: a narrative review. J Hosp Infect 2024; 149:189-200. [PMID: 38621512 DOI: 10.1016/j.jhin.2024.02.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/12/2024] [Accepted: 02/21/2024] [Indexed: 04/17/2024]
Abstract
Non-ventilated hospital-acquired pneumonia (NV-HAP) is associated with a significant healthcare burden, arising from high incidence and associated morbidity and mortality. However, accurate identification of cases remains challenging. At present, there is no gold-standard test for the diagnosis of NV-HAP, requiring instead the blending of non-specific signs and investigations. Causative organisms are only identified in a minority of cases. This has significant implications for surveillance, patient outcomes and antimicrobial stewardship. Much of the existing research in HAP has been conducted among ventilated patients. The paucity of dedicated NV-HAP research means that conclusions regarding diagnostic methods, pathology and interventions must largely be extrapolated from work in other settings. Progress is also limited by the lack of a widely agreed definition for NV-HAP. The diagnosis of NV-HAP has large scope for improvement. Consensus regarding a case definition will allow meaningful research to improve understanding of its aetiology and the heterogeneity of outcomes experienced by patients. There is potential to optimize the role of imaging and to incorporate novel techniques to identify likely causative pathogens. This would facilitate both antimicrobial stewardship and surveillance of an important healthcare-associated infection. This narrative review considers the utility of existing methods to diagnose NV-HAP, with a focus on the significance and challenge of identifying pathogens. It discusses the limitations in current techniques, and explores the potential of emergent molecular techniques to improve microbiological diagnosis and outcomes for patients.
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Affiliation(s)
- S Quarton
- National Institute for Health Research Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, UK.
| | - A Livesey
- National Institute for Health Research/Wellcome Trust Clinical Research Facility, University Hospitals Birmingham, Birmingham, UK
| | - H Pittaway
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham, Birmingham, UK
| | - A Adiga
- Warwick Hospital, South Warwickshire University NHS Foundation Trust, Warwick, UK
| | - F Grudzinska
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - A McNally
- Institute of Microbiology and Infection, University of Birmingham, Birmingham, UK
| | - D Dosanjh
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - E Sapey
- National Institute for Health Research Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, UK; National Institute for Health Research Midlands Patient Safety Research Collaboration, University of Birmingham, Birmingham, UK; National Institute for Health Research Midlands Applied Research Collaborative, University of Birmingham, Birmingham, UK
| | - D Parekh
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
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Valentine JC, Gillespie E, Verspoor KM, Hall L, Worth LJ. Performance of ICD-10-AM codes for quality improvement monitoring of hospital-acquired pneumonia in a haematology-oncology casemix in Victoria, Australia. HEALTH INF MANAG J 2024; 53:112-120. [PMID: 36374542 DOI: 10.1177/18333583221131753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
BACKGROUND The Australian hospital-acquired complication (HAC) policy was introduced to facilitate negative funding adjustments in Australian hospitals using ICD-10-AM codes. OBJECTIVE The aim of this study was to determine the positive predictive value (PPV) of the ICD-10-AM codes in the HAC framework to detect hospital-acquired pneumonia in patients with cancer and to describe any change in PPV before and after implementation of an electronic medical record (EMR) at our centre. METHOD A retrospective case review of all coded pneumonia episodes at the Peter MacCallum Cancer Centre in Melbourne, Australia spanning two time periods (01 July 2015 to 30 June 2017 [pre-EMR period] and 01 September 2020 to 28 February 2021 [EMR period]) was performed to determine the proportion of events satisfying standardised surveillance definitions. RESULTS HAC-coded pneumonia occurred in 3.66% (n = 151) of 41,260 separations during the study period. Of the 151 coded pneumonia separations, 27 satisfied consensus surveillance criteria, corresponding to an overall PPV of 0.18 (95% CI: 0.12, 0.25). The PPV was approximately three times higher following EMR implementation (0.34 [95% CI: 0.19, 0.53] versus 0.13 [95% CI: 0.08, 0.21]; p = .013). CONCLUSION The current HAC definition is a poor-to-moderate classifier for hospital-acquired pneumonia in patients with cancer and, therefore, may not accurately reflect hospital-level quality improvement. Implementation of an EMR did enhance case detection, and future refinements to administratively coded data in support of robust monitoring frameworks should focus on EMR systems. IMPLICATIONS Although ICD-10-AM data are readily available in Australian healthcare settings, these data are not sufficient for monitoring and reporting of hospital-acquired pneumonia in haematology-oncology patients.
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Affiliation(s)
- Jake C Valentine
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia
| | - Elizabeth Gillespie
- Infection Prevention Unit, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Karin M Verspoor
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- School of Computing and Information Systems, University of Melbourne, Parkville, VIC, Australia
| | - Lisa Hall
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- School of Public Health, University of Queensland, Brisbane, QLD, Australia
| | - Leon J Worth
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia
- Infection Prevention Unit, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
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Hanquet G, Theilacker C, Vietri J, Sepúlveda-Pachón I, Menon S, Gessner B, Begier E. Best Practices for Identifying Hospitalized Lower Respiratory Tract Infections Using Administrative Data: A Systematic Literature Review of Validation Studies. Infect Dis Ther 2024; 13:921-940. [PMID: 38498108 PMCID: PMC11058181 DOI: 10.1007/s40121-024-00949-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 02/22/2024] [Indexed: 03/20/2024] Open
Abstract
INTRODUCTION Estimating the burden of lower respiratory tract infections (LRTIs) increasingly relies on administrative databases using International Classification of Diseases (ICD) codes, but no standard methodology exists. We defined best practices for ICD-based algorithms that estimate LRTI incidence in adults. METHODS We conducted a systematic review of validation studies assessing the use of ICD code-based algorithms to identify hospitalized LRTIs in adults, published in Medline, EMBASE, and LILACS between January 1996 and January 2022, according to PRISMA guidelines. We assessed sensitivity, specificity, and other accuracy measures of different algorithms. RESULTS We included 26 publications that used a variety of ICD code-based algorithms and gold standard criteria, and 18 reported sensitivity and/or specificity. Sensitivity was below 80% in 72% (38/53) of algorithms and specificity exceeded 90% in 77% (37/48). Algorithms for all-cause LRTI (n = 18) that included only pneumonia codes in primary position (n = 3) had specificity greater than 90% but low sensitivity (55-72%). Sensitivity increased by 5-15%, with minimal loss in specificity, with the addition of primary codes for severe pneumonia (e.g. sepsis) while pneumonia codes were in secondary position, and by 13% with codes from LRTI-related infections (e.g. viral) or other respiratory diseases (e.g. empyema). Sensitivity increased by 8% when pneumonia codes were in any position, but specificity was not reported. In hospital-acquired pneumonia and pneumococcal-specific pneumonia, algorithms containing only nosocomial- or pathogen-specific ICD codes had poor sensitivity, which improved when broader pneumonia codes were added, in particular codes for unspecified organisms. CONCLUSION Our systematic review highlights that most ICD code-based algorithms are relatively specific, but miss a substantial number of hospitalized LRTI adult cases. Best practices to estimate LRTI incidence in this population include the use of all pneumonia ICD codes for any LRTI outcome and, to a lesser extent, those for other LRTI-related infections or respiratory diseases.
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Affiliation(s)
- Germaine Hanquet
- P95 Epidemiology and Pharmacovigilance, Koning Leopold III Laan 1, 3001, Louvain, Belgium
| | | | - Jeffrey Vietri
- Pfizer Inc., 500 Arcola Rd, Collegeville, PA, 19426, USA
| | | | - Sonia Menon
- P95 Epidemiology and Pharmacovigilance, Koning Leopold III Laan 1, 3001, Louvain, Belgium
| | | | - Elizabeth Begier
- Scientific Affairs, Older Adult RSV Vaccine Program, Global Medical Development Scientific and Clinical Affairs, Pfizer Vaccines, Pfizer Inc., 9 Riverwalk, Citywest Business Campus, Dublin 24, Dublin, Ireland.
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Wolfensberger A, Scherrer AU, Sax H. Automated surveillance of non-ventilator-associated hospital-acquired pneumonia (nvHAP): a systematic literature review. Antimicrob Resist Infect Control 2024; 13:30. [PMID: 38449045 PMCID: PMC10918924 DOI: 10.1186/s13756-024-01375-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 01/31/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND Hospital-acquired pneumonia (HAP) and its specific subset, non-ventilator hospital-acquired pneumonia (nvHAP) are significant contributors to patient morbidity and mortality. Automated surveillance systems for these healthcare-associated infections have emerged as a potentially beneficial replacement for manual surveillance. This systematic review aims to synthesise the existing literature on the characteristics and performance of automated nvHAP and HAP surveillance systems. METHODS We conducted a systematic search of publications describing automated surveillance of nvHAP and HAP. Our inclusion criteria covered articles that described fully and semi-automated systems without limitations on patient demographics or healthcare settings. We detailed the algorithms in each study and reported the performance characteristics of automated systems that were validated against specific reference methods. Two published metrics were employed to assess the quality of the included studies. RESULTS Our review identified 12 eligible studies that collectively describe 24 distinct candidate definitions, 23 for fully automated systems and one for a semi-automated system. These systems were employed exclusively in high-income countries and the majority were published after 2018. The algorithms commonly included radiology, leukocyte counts, temperature, antibiotic administration, and microbiology results. Validated surveillance systems' performance varied, with sensitivities for fully automated systems ranging from 40 to 99%, specificities from 58 and 98%, and positive predictive values from 8 to 71%. Validation was often carried out on small, pre-selected patient populations. CONCLUSIONS Recent years have seen a steep increase in publications on automated surveillance systems for nvHAP and HAP, which increase efficiency and reduce manual workload. However, the performance of fully automated surveillance remains moderate when compared to manual surveillance. The considerable heterogeneity in candidate surveillance definitions and reference standards, as well as validation on small or pre-selected samples, limits the generalisability of the findings. Further research, involving larger and broader patient populations is required to better understand the performance and applicability of automated nvHAP surveillance.
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Affiliation(s)
- Aline Wolfensberger
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.
- Institute for Implementation Science in Healthcare, University of Zurich, Zurich, Switzerland.
| | - Alexandra U Scherrer
- Department of Infectious Diseases, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Hugo Sax
- Department of Infectious Diseases, Bern University Hospital and University of Bern, Bern, Switzerland
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Samadani A, Wang T, van Zon K, Celi LA. VAP risk index: Early prediction and hospital phenotyping of ventilator-associated pneumonia using machine learning. Artif Intell Med 2023; 146:102715. [PMID: 38042602 DOI: 10.1016/j.artmed.2023.102715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 11/03/2023] [Accepted: 11/05/2023] [Indexed: 12/04/2023]
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is a leading cause of morbidity and mortality in intensive care units (ICUs). Early identification of patients at risk of VAP enables early intervention, which in turn improves patient outcomes. We developed a predictive model for individualized risk assessment utilizing machine learning to identify patients at risk of developing VAP. METHODS The Philips eRI dataset, a multi-institution electronic medical record (EMR), was used for model development. For adult (≥18y) patients, we propose a set of criteria using indications of the start of a new antibiotic treatment temporally contiguous to a microbiological test to mark suspected infection events, of which those with a positive culture are labeled as presumed VAP if 1) the event occurs at least 48 h after intubation, and 2) there are no indications of community-acquired pneumonia (CAP) or other hospital-acquired infections (HAI) in the patient charts. The resulting VAP and no-VAP (control) cases were then used to build an ensemble of decision trees to predict the risk of VAP in the next 24 h using data on patients' demographics, vitals, labs, and ventilator settings. RESULTS The resulting model predicts the development of VAP 24 h in advance with an AUC of 76 % and AUPRC of 75 %. Additionally, we group hospitals that are similar in healthcare processes into distinct clusters and characterize VAP prediction for the identified hospital clusters. We show inter-hospital (teaching status and healthcare processes) and cohort-specific (age groups, gender, early vs late VAP, ICU mortality status) differences in VAP prediction and associated symptomologies. CONCLUSIONS Our proposed VAP criteria use clinical actions to mark incidences of presumed VAP infection, which enables the development of models for early detection of these events. We curated a patient cohort using these criteria and used it to build a model for predicting impending VAP events prior to clinical suspicions. We present a clustering approach for tailoring the VAP prediction model for different hospital types based on their EMR data characteristics. The model provides an instantaneous risk score that allows early interventions and confirmatory diagnostic actions.
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Affiliation(s)
- Ali Samadani
- Philips Research North America, Cambridge, MA, USA.
| | - Taiyao Wang
- Philips Research North America, Cambridge, MA, USA
| | - Kees van Zon
- Philips Research North America, Cambridge, MA, USA
| | - Leo Anthony Celi
- Massachusetts Institute of Technology, Laboratory for Computational Physiology, Cambridge, MA, USA; Beth Israel Deaconess Medical Center, Division of Pulmonary, Critical Care, and Sleep Medicine, Boston, MA, USA
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Rose N, Spoden M, Freytag A, Pletz M, Eckmanns T, Wedekind L, Storch J, Schlattmann P, Hartog CS, Reinhart K, Günster C, Fleischmann-Struzek C. Association between hospital onset of infection and outcomes in sepsis patients - A propensity score matched cohort study based on health claims data in Germany. Int J Med Microbiol 2023; 313:151593. [PMID: 38070459 DOI: 10.1016/j.ijmm.2023.151593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 11/24/2023] [Accepted: 11/28/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Hospital-acquired infections are a common source of sepsis. Hospital onset of sepsis was found to be associated with higher acute mortality and hospital costs, yet its impact on long-term patient-relevant outcomes and costs is unknown. OBJECTIVE We aimed to assess the association between sepsis origin and acute and long-term outcomes based on a nationwide population-based cohort of sepsis patients in Germany. METHODS This retrospective cohort study used nationwide health claims data from 23 million health insurance beneficiaries. Sepsis patients with hospital-acquired infections (HAI) were identified by ICD-10-codes in a cohort of adult patients with hospital-treated sepsis between 2013 and 2014. Cases without these ICD-10-codes were considered as sepsis cases with community-acquired infection (CAI) and were matched with HAI sepsis patients by propensity score matching. Outcomes included in-hospital/12-month mortality and costs, as well as readmissions and nursing care dependency until 12 months postsepsis. RESULTS We matched 33,110 HAI sepsis patients with 28,614 CAI sepsis patients and 22,234 HAI sepsis hospital survivors with 19,364 CAI sepsis hospital survivors. HAI sepsis patients had a higher hospital mortality than CAI sepsis patients (32.8% vs. 25.4%, RR 1.3, p < .001). Similarly, 12-months postacute mortality was higher (37.2% vs. 30.1%, RR=1.2, p < .001). Hospital and 12-month health care costs were 178% and 22% higher in HAI patients than in CAI patients, respectively. Twelve months postsepsis, HAI sepsis survivors were more often newly dependent on nursing care (33.4% vs. 24.0%, RR=1.4, p < .001) and experienced 5% more hospital readmissions (mean number of readmissions: 2.1 vs. 2.0, p < .001). CONCLUSIONS HAI sepsis patients face an increased risk of adverse outcomes both during the acute sepsis episode and in the long-term. Measures to prevent HAI and its progression into sepsis may be an opportunity to mitigate the burden of long-term impairments and costs of sepsis, e.g., by early detection of HAI progressing into sepsis, particularly in normal wards; adequate sepsis management and adherence to sepsis bundles in hospital-acquired sepsis; and an improved infection prevention and control.
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Affiliation(s)
- Norman Rose
- Institute of Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany; Center for Sepsis Control and Care, Jena University Hospital/Friedrich Schiller University Jena, Jena, Germany
| | - Melissa Spoden
- Research Institute of the Local Health Care Funds, Berlin, Germany/ Federal Association of the Local Health Care Funds, Berlin, Germany
| | - Antje Freytag
- Institute of General Practice and Family Medicine, Jena University Hospital, Jena, Germany
| | - Mathias Pletz
- Institute of Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
| | - Tim Eckmanns
- Department of Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | - Lisa Wedekind
- Institute of Medical Statistics, Computer and Data Sciences, Jena University Hospital, Jena, Germany
| | - Josephine Storch
- Institute of General Practice and Family Medicine, Jena University Hospital, Jena, Germany
| | - Peter Schlattmann
- Institute of Medical Statistics, Computer and Data Sciences, Jena University Hospital, Jena, Germany
| | - Christiane S Hartog
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany; Klinik Bavaria, Kreischa, Germany
| | - Konrad Reinhart
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Christian Günster
- Research Institute of the Local Health Care Funds, Berlin, Germany/ Federal Association of the Local Health Care Funds, Berlin, Germany
| | - Carolin Fleischmann-Struzek
- Institute of Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany; Center for Sepsis Control and Care, Jena University Hospital/Friedrich Schiller University Jena, Jena, Germany.
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Jones BE, Sarvet AL, Ying J, Jin R, Nevers MR, Stern SE, Ocho A, McKenna C, McLean LE, Christensen MA, Poland RE, Guy JS, Sands KE, Rhee C, Young JG, Klompas M. Incidence and Outcomes of Non-Ventilator-Associated Hospital-Acquired Pneumonia in 284 US Hospitals Using Electronic Surveillance Criteria. JAMA Netw Open 2023; 6:e2314185. [PMID: 37200031 PMCID: PMC10196873 DOI: 10.1001/jamanetworkopen.2023.14185] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 03/30/2023] [Indexed: 05/19/2023] Open
Abstract
Importance Non-ventilator-associated hospital-acquired pneumonia (NV-HAP) is a common and deadly hospital-acquired infection. However, inconsistent surveillance methods and unclear estimates of attributable mortality challenge prevention. Objective To estimate the incidence, variability, outcomes, and population attributable mortality of NV-HAP. Design, Setting, and Participants This cohort study retrospectively applied clinical surveillance criteria for NV-HAP to electronic health record data from 284 US hospitals. Adult patients admitted to the Veterans Health Administration hospital from 2015 to 2020 and HCA Healthcare hospitals from 2018 to 2020 were included. The medical records of 250 patients who met the surveillance criteria were reviewed for accuracy. Exposures NV-HAP, defined as sustained deterioration in oxygenation for 2 or more days in a patient who was not ventilated concurrent with abnormal temperature or white blood cell count, performance of chest imaging, and 3 or more days of new antibiotics. Main Outcomes and Measures NV-HAP incidence, length-of-stay, and crude inpatient mortality. Attributable inpatient mortality by 60 days follow-up was estimated using inverse probability weighting, accounting for both baseline and time-varying confounding. Results Among 6 022 185 hospitalizations (median [IQR] age, 66 [54-75] years; 1 829 475 [26.1%] female), there were 32 797 NV-HAP events (0.55 per 100 admissions [95% CI, 0.54-0.55] per 100 admissions and 0.96 per 1000 patient-days [95% CI, 0.95-0.97] per 1000 patient-days). Patients with NV-HAP had multiple comorbidities (median [IQR], 6 [4-7]), including congestive heart failure (9680 [29.5%]), neurologic conditions (8255 [25.2%]), chronic lung disease (6439 [19.6%]), and cancer (5,467 [16.7%]); 24 568 cases (74.9%) occurred outside intensive care units. Crude inpatient mortality was 22.4% (7361 of 32 797) for NV-HAP vs 1.9% (115 530 of 6 022 185) for all hospitalizations; 12 449 (8.0%) were discharged to hospice. Median [IQR] length-of-stay was 16 (11-26) days vs 4 (3-6) days. On medical record review, pneumonia was confirmed by reviewers or bedside clinicians in 202 of 250 patients (81%). It was estimated that NV-HAP accounted for 7.3% (95% CI, 7.1%-7.5%) of all hospital deaths (total hospital population inpatient death risk of 1.87% with NV-HAP events included vs 1.73% with NV-HAP events excluded; risk ratio, 0.927; 95% CI, 0.925-0.929). Conclusions and Relevance In this cohort study, NV-HAP, which was defined using electronic surveillance criteria, was present in approximately 1 in 200 hospitalizations, of whom 1 in 5 died in the hospital. NV-HAP may account for up to 7% of all hospital deaths. These findings underscore the need to systematically monitor NV-HAP, define best practices for prevention, and track their impact.
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Affiliation(s)
- Barbara E. Jones
- Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City
- VA Salt Lake City Health Care System, Salt Lake City, Utah
| | - Aaron L. Sarvet
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Jian Ying
- Division of Epidemiology, University of Utah, Salt Lake City
| | - Robert Jin
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | | | - Sarah E. Stern
- Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City
| | - Aileen Ocho
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Caroline McKenna
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | | | - Matthew A. Christensen
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Russell E. Poland
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- HCA Healthcare Inc, Nashville, Tennessee
| | | | - Kenneth E. Sands
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- HCA Healthcare Inc, Nashville, Tennessee
| | - Chanu Rhee
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Department of Medicine, Brigham Women’s Hospital, Boston, Massachusetts
| | - Jessica G. Young
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Department of Medicine, Brigham Women’s Hospital, Boston, Massachusetts
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Electronic surveillance criteria for non-ventilator-associated hospital-acquired pneumonia: Assessment of reliability and validity. Infect Control Hosp Epidemiol 2023:1-7. [PMID: 36920040 DOI: 10.1017/ice.2022.302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
OBJECTIVE Surveillance of non-ventilator-associated hospital-acquired pneumonia (NV-HAP) is complicated by subjectivity and variability in diagnosing pneumonia. We compared a fully automatable surveillance definition using routine electronic health record data to manual determinations of NV-HAP according to surveillance criteria and clinical diagnoses. METHODS We retrospectively applied an electronic surveillance definition for NV-HAP to all adults admitted to Veterans' Affairs (VA) hospitals from January 1, 2015, to November 30, 2020. We randomly selected 250 hospitalizations meeting NV-HAP surveillance criteria for independent review by 2 clinicians and calculated the percent of hospitalizations with (1) clinical deterioration, (2) CDC National Healthcare Safety Network (CDC-NHSN) criteria, (3) NV-HAP according to a reviewer, (4) NV-HAP according to a treating clinician, (5) pneumonia diagnosis in discharge summary; and (6) discharge diagnosis codes for HAP. We assessed interrater reliability by calculating simple agreement and the Cohen κ (kappa). RESULTS Among 3.1 million hospitalizations, 14,023 met NV-HAP electronic surveillance criteria. Among reviewed cases, 98% had a confirmed clinical deterioration; 67% met CDC-NHSN criteria; 71% had NV-HAP according to a reviewer; 60% had NV-HAP according to a treating clinician; 49% had a discharge summary diagnosis of pneumonia; and 82% had NV-HAP according to any definition according to at least 1 reviewer. Only 8% had diagnosis codes for HAP. Interrater agreement was 75% (κ = 0.50) for CDC-NHSN criteria and 78% (κ = 0.55) for reviewer diagnosis of NV-HAP. CONCLUSIONS Electronic NV-HAP surveillance criteria correlated moderately with existing manual surveillance criteria. Reviewer variability for all manual assessments was high. Electronic surveillance using clinical data may therefore allow for more consistent and efficient surveillance with similar accuracy compared to manual assessments or diagnosis codes.
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Munro SC, Baker D, Giuliano KK, Sullivan SC, Haber J, Jones BE, Crist MB, Nelson RE, Carey E, Lounsbury O, Lucatorto M, Miller R, Pauley B, Klompas M. Nonventilator hospital-acquired pneumonia: A call to action. Infect Control Hosp Epidemiol 2021; 42:991-996. [PMID: 34103108 PMCID: PMC10947501 DOI: 10.1017/ice.2021.239] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In 2020 a group of U.S. healthcare leaders formed the National Organization to Prevent Hospital-Acquired Pneumonia (NOHAP) to issue a call to action to address non-ventilator-associated hospital-acquired pneumonia (NVHAP). NVHAP is one of the most common and morbid healthcare-associated infections, but it is not tracked, reported, or actively prevented by most hospitals. This national call to action includes (1) launching a national healthcare conversation about NVHAP prevention; (2) adding NVHAP prevention measures to education for patients, healthcare professionals, and students; (3) challenging healthcare systems and insurers to implement and support NVHAP prevention; and (4) encouraging researchers to develop new strategies for NVHAP surveillance and prevention. The purpose of this document is to outline research needs to support the NVHAP call to action. Primary needs include the development of better models to estimate the economic cost of NVHAP, to elucidate the pathophysiology of NVHAP and identify the most promising pathways for prevention, to develop objective and efficient surveillance methods to track NVHAP, to rigorously test the impact of prevention strategies proposed to prevent NVHAP, and to identify the policy levers that will best engage hospitals in NVHAP surveillance and prevention. A joint task force developed this document including stakeholders from the Veterans' Health Administration (VHA), the U.S. Centers for Disease Control and Prevention (CDC), The Joint Commission, the American Dental Association, the Patient Safety Movement Foundation, Oral Health Nursing Education and Practice (OHNEP), Teaching Oral-Systemic Health (TOSH), industry partners and academia.
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Affiliation(s)
- Shannon C. Munro
- Research and Development, Salem Veterans’ Affairs Medical Center, Salem
| | - Dian Baker
- School of Nursing, California State University, Sacramento, California
| | - Karen K. Giuliano
- College of Nursing & Institute for Applied Life Sciences, University of Massachusetts–Amherst, Amherst, Massachusetts
| | - Sheila C. Sullivan
- Research, Evidence Based Practice and Analytics, Office of Nursing Services, Department of Veterans’ Affairs, Washington, DC
| | - Judith Haber
- Oral Health Nursing Education and Practice, Rory Meyers College of Nursing, New York University, New York, New York
| | - Barbara E. Jones
- Pulmonary & Critical Care Medicine, University of Utah, Salt Lake City, Utah
- Salt Lake City Veterans’ Affairs Healthcare System, Salt Lake City, Utah
| | - Matthew B. Crist
- Division of Health Care Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Richard E. Nelson
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah
- George E. Wahlen Department of Veterans’ Affairs Medical Center, Salt Lake City, Utah
| | - Evan Carey
- Research and Development, Rocky Mountain Regional Veterans’ Affairs Medical Center, Aurora, Colorado
| | | | - Michelle Lucatorto
- Office of Nursing Services, Department of Veterans’ Affairs, Washington, DC
| | - Ryan Miller
- Office of Nursing Services, Department of Veterans’ Affairs, Washington, DC
| | - Brian Pauley
- Geriatrics & Extended Care, Veterans’ Affairs Pacific Islands Healthcare System, Honolulu, Hawaii
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston
- Department of Medicine, Brigham and Women’s Hospital, Boston
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10
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López-de-Andrés A, Albaladejo-Vicente R, de Miguel-Diez J, Hernández-Barrera V, Ji Z, Zamorano-León JJ, Lopez-Herranz M, Carabantes Alarcon D, Jimenez-Garcia R. Gender differences in incidence and in-hospital outcomes of community-acquired, ventilator-associated and nonventilator hospital-acquired pneumonia in Spain. Int J Clin Pract 2021; 75:e13762. [PMID: 33068052 DOI: 10.1111/ijcp.13762] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 10/04/2020] [Indexed: 12/20/2022] Open
Abstract
AIMS We aim to compare the incidence and in-hospital outcomes of community-acquired pneumonia (CAP), ventilator-associated pneumonia (VAP) and nonventilator hospital-acquired pneumonia (NV-HAP) according to gender. METHODS This was a retrospective observational epidemiological study using the Spanish National Hospital Discharge Database for the years 2016 and 2017. RESULTS Of 277 785 hospital admissions, CAP was identified in 257 455 (41.04% females), VAP was identified in 3261 (30.42% females) and NV-HAP was identified in 17 069 (36.58% females). The incidence of all types of pneumonia was higher amongst males (CAP: incidence rate ratio [IRR] 1.05, 95% CI 1.03-1.06; VAP: IRR 1.36, 95% CI 1.26-1.46; and NV-HAP: IRR 1.16, 95% CI 1.14-1.18). The crude in-hospital mortality (IHM) rate for CAP was 11.44% in females and 11.80% in males (P = .005); for VAP IHM, the rate was approximately 35% in patients of both genders and for NV-HAP IHM, the rate was 23.97% for females and 26.40% for males (P < .001). After multivariable adjustment, in patients of both genders, older age and comorbidities were factors associated with IHM in the three types of pneumonia analysed. Female gender was a risk factor for IHM after VAP (OR 1.24; 95% CI 1.06-1.44), and no gender differences were found for CAP or NV-HAP. CONCLUSIONS Our findings show a difference between females and males, with females presenting a lower incidence of all types of pneumonia. However, female gender was a risk factor for IHM after VAP.
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Affiliation(s)
- Ana López-de-Andrés
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, Alcorcón, Spain
| | - Romana Albaladejo-Vicente
- Department of Public Health & Maternal and Child Health, Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Javier de Miguel-Diez
- Respiratory Department, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - Valentín Hernández-Barrera
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, Alcorcón, Spain
| | - Zichen Ji
- Respiratory Department, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - José J Zamorano-León
- Department of Public Health & Maternal and Child Health, Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Marta Lopez-Herranz
- Faculty of Nursing, Physiotherapy and Podology, Universidad Complutense de Madrid, Madrid, Spain
| | - David Carabantes Alarcon
- Department of Public Health & Maternal and Child Health, Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Rodrigo Jimenez-Garcia
- Department of Public Health & Maternal and Child Health, Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain
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11
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A successful program preventing nonventilator hospital-acquired pneumonia in a large hospital system. Infect Control Hosp Epidemiol 2020; 41:547-552. [DOI: 10.1017/ice.2019.368] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractObjective:To develop and evaluate a program to presvent hospital-acquired pneumonia (HAP).Design:Prospective, observational, surveillance program to identify HAP before and after 7 interventions. An order set automatically triggered in programmatically identified high-risk patients.Setting:All 21 hospitals of an integrated healthcare system with 4.4 million members.Patients:All hospitalized patients.Interventions:Interventions for high-risk patients included mobilization, upright feeding, swallowing evaluation, sedation restrictions, elevated head of bed, oral care and tube care.Results:HAP rates decreased between 2012 and 2018: from 5.92 to 1.79 per 1,000 admissions (P = .0031) and from 24.57 to 6.49 per 100,000 members (P = .0014). HAP mortality decreased from 1.05 to 0.34 per 1,000 admissions and from 4.37 to 1.24 per 100,000 members. Concomitant antibiotic utilization demonstrated reductions of broad-spectrum antibiotics. Antibiotic therapy per 100,000 members was measured as follows: carbapenem days (694 to 463; P = .0020), aminoglycoside days (154 to 61; P = .0165), vancomycin days (2,087 to 1,783; P = .002), and quinolone days (2,162 to 1,287; P < .0001). Only cephalosporin use increased, driven by ceftriaxone days (264 to 460; P = .0009). Benzodiazepine use decreased between 2014 to 2016: 10.4% to 8.8% of inpatient days. Mortality for patients with HAP was 18% in 2012% and 19% in 2016 (P = .439).Conclusion:HAP rates, mortality, and broad-spectrum antibiotic use were all reduced significantly following these interventions, despite the absence of strong supportive literature for guidance. Most interventions augmented basic nursing care. None had risks of adverse consequences. These results support the need to examine practices to improve care despite limited literature and the need to further study these difficult areas of care.
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12
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Accuracy and reliability of electronic versus CDC surveillance criteria for non-ventilator hospital-acquired pneumonia. Infect Control Hosp Epidemiol 2019; 41:219-221. [PMID: 31818337 DOI: 10.1017/ice.2019.329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Nonventilator hospital-acquired pneumonia (NV-HAP) is one of the most common healthcare-associated infections, but most hospitals do not track it. We created a pilot electronic definition for NV-HAP and compared its accuracy to Centers for Disease Control and Prevention (CDC) criteria. Kappa values for the electronic definition and CDC criteria versus "true" pneumonia were similar: 0.40 and 0.47, respectively.
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13
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Ji W, McKenna C, Ochoa A, Ramirez Batlle H, Young J, Zhang Z, Rhee C, Clark R, Shenoy ES, Hooper D, Klompas M. Development and Assessment of Objective Surveillance Definitions for Nonventilator Hospital-Acquired Pneumonia. JAMA Netw Open 2019; 2:e1913674. [PMID: 31626321 PMCID: PMC6813588 DOI: 10.1001/jamanetworkopen.2019.13674] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
IMPORTANCE Hospital-acquired pneumonia is the most common health care-associated infection in the United States. Most cases occur in nonventilated patients, but many hospitals track hospital-acquired pneumonia only in ventilated patients because of the complexity and subjectivity of conducting surveillance for large numbers of nonventilated patients. OBJECTIVE To propose and assess potentially objective, efficient, and reproducible surveillance definitions for nonventilator hospital-acquired pneumonia (NV-HAP) using routine clinical data stored in electronic health record systems. DESIGN, SETTING, AND PARTICIPANTS This cohort study was conducted in 2 tertiary referral and 2 community hospitals in Massachusetts between May 31, 2015, and July 1, 2018. All nonventilated patients aged 18 years or older who were admitted to these hospitals were included (N = 310 651). EXPOSURES Ten candidate definitions for NV-HAP based on clinically meaningful combinations of 6 potential surveillance criteria were proposed: worsening oxygenation, temperature higher than 38 °C (fever), abnormal white blood cell count of less than 4000/μL or more than 12 000/μL, performance of chest imaging, submission of respiratory specimen for culture, and 3 or more days of new antibiotics. MAIN OUTCOMES AND MEASURES Incidence rates, lengths of stay, hospital mortality rates, and odds ratios (ORs) for time to discharge and mortality compared with those of matched controls were calculated for each candidate definition. The ORs were adjusted for demographics, clinical service, comorbidities, and severity of illness. RESULTS The study analyzed 310 651 patients with 489 519 admissions, including 205 054 patients with 311 484 admissions of 3 or more days. Among the patients with 311 484 admissions, the mean (SD) patient age was 58.3 (19.3) years and 176 936 (56.8%) were of women. Incidence rates for candidate definitions per 100 admissions ranged from 3.4 events for worsening oxygenation alone to 0.9 event for worsening oxygenation and at least 3 days of new antibiotics to 0.6 event for worsening oxygenation, at least 3 days of new antibiotics, fever, abnormal white blood cell count, and performance of chest imaging. Crude mortality rates ranged from 16.1% (n = 2643) for patients with worsening oxygen alone to 27.7% (n = 868) for patients with worsening oxygenation, at least 3 days of antibiotics, fever or abnormal white blood cell count, and chest imaging. Patients who met NV-HAP candidate definitions remained in the hospital for twice as long as their matched controls (adjusted ORs ranged from 1.8 [95% CI, 1.7-1.8] to 2.1 [95% CI, 2.0-2.1]) and were 4 to 6 times as likely to die in the hospital (adjusted ORs ranged from 3.8 [95% CI, 3.5-4.0] to 6.5 [95% CI, 5.2-8.2]). Agreement between candidate definitions and clinical diagnoses was fair (κ = 0.33). CONCLUSIONS AND RELEVANCE These findings suggest that objective surveillance for NV-HAP using electronically computable definitions that incorporate common clinical criteria is feasible and generates incidence, mortality, and adjusted ORs for hospital mortality similar to estimates from manual surveillance. These definitions have the potential to facilitate widespread, automated surveillance for NV-HAP and thus inform the development and evaluation of prevention programs.
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Affiliation(s)
- Wenjing Ji
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi’an Jiaotong University, Xi’an, Shaanxi, China
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Caroline McKenna
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Aileen Ochoa
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | | | - Jessica Young
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Zilu Zhang
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Chanu Rhee
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Roger Clark
- Department of Medicine, Brigham and Women’s Faulkner Hospital, Boston, Massachusetts
| | - Erica S. Shenoy
- Department of Medicine and Infection Control Unit, Massachusetts General Hospital, Boston
| | - David Hooper
- Department of Medicine and Infection Control Unit, Massachusetts General Hospital, Boston
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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14
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Wolfensberger A, Jakob W, Faes Hesse M, Kuster SP, Meier AH, Schreiber PW, Clack L, Sax H. Development and validation of a semi-automated surveillance system-lowering the fruit for non-ventilator-associated hospital-acquired pneumonia (nvHAP) prevention. Clin Microbiol Infect 2019; 25:1428.e7-1428.e13. [PMID: 30922931 PMCID: PMC7128786 DOI: 10.1016/j.cmi.2019.03.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 03/01/2019] [Accepted: 03/16/2019] [Indexed: 11/04/2022]
Abstract
Objectives Conducting manual surveillance of non-ventilator-associated hospital-acquired pneumonia (nvHAP) using ECDC (European Centre for Disease Prevention and Control) surveillance criteria is very resource intensive. We developed and validated a semi-automated surveillance system for nvHAP, and describe nvHAP incidence and aetiology at our hospital. Methods We applied an automated classification algorithm mirroring ECDC definition criteria to distinguish patients ‘not at risk’ from patients ‘at risk’ for suffering from nvHAP. ‘At risk’-patients were manually screened for nvHAP. For validation, we applied the reference standard of full manual evaluation to three validation samples comprising 2091 patients. Results Among the 39 519 University Hospital Zurich inpatient discharges in 2017, the algorithm identified 2454 ‘at-risk’ patients, reducing the number of medical records to be manually screened by 93.8%. From this subset, nvHAP was identified in 251 patients (0.64%, 95%CI: 0.57–0.73). Sensitivity, negative predictive value, and accuracy of semi-automated surveillance versus full manual surveillance were lowest in the validation sample consisting of patients with HAP according to the International Classification of Diseases (ICD-10) discharge diagnostic codes, with 97.5% (CI: 93.7–99.3%), 99.2% (CI: 97.9–99.8%), and 99.4% (CI: 98.4–99.8%), respectively. The overall incidence rate of nvHAP was 0.83/1000 patient days (95%CI: 0.73–0.94), with highest rates in haematology/oncology, cardiac and thoracic surgery, and internal medicine including subspecialties. Conclusions The semi-automated surveillance demonstrated a very high sensitivity, negative predictive value, and accuracy. This approach significantly reduces manual surveillance workload, thus making continuous nvHAP surveillance feasible as a pivotal element for successful prevention efforts.
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Affiliation(s)
- A Wolfensberger
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zürich, University of Zurich, Zurich, Switzerland.
| | - W Jakob
- Department of Medical Data Management Systems, ICT Directorate, University Hospital Zurich, Zurich, Switzerland
| | - M Faes Hesse
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zürich, University of Zurich, Zurich, Switzerland
| | - S P Kuster
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zürich, University of Zurich, Zurich, Switzerland
| | - A H Meier
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zürich, University of Zurich, Zurich, Switzerland
| | - P W Schreiber
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zürich, University of Zurich, Zurich, Switzerland
| | - L Clack
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zürich, University of Zurich, Zurich, Switzerland
| | - H Sax
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zürich, University of Zurich, Zurich, Switzerland
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15
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Chen D, Hu X, Chen F, Li H, Wang D, Li X, Wu C, Li N, Wu S, Li Z, Chen L, Chen Y. Co-outbreak of multidrug resistance and a novel ST3006 Klebsiella pneumoniae in a neonatal intensive care unit: A retrospective study. Medicine (Baltimore) 2019; 98:e14285. [PMID: 30681632 PMCID: PMC6358387 DOI: 10.1097/md.0000000000014285] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
The outbreak of carbapenem-resistant Klebsiella pneumoniae is a serious public health problem, especially in the neonatal intensive care unit (NICU).Fifteen K. pneumoniae strains were isolated from 7 neonates during June 3 to 28, 2017 in an NICU. Antimicrobial susceptibility was determined by the Vitek 2 system and microbroth dilution method. Multilocus sequence typing (MLST) and pulsed-field gel electrophoresis (PFGE) were used to analyze the genetic relatedness of the isolates. Whole-genome sequencing and gene function analysis were performed to investigate pathogenicity and drug resistance and screen genomic islands.Three clones of K. pneumoniae were identified from 7 neonates: 7 strains of ST37, 7 of novel ST3006, and 1 of ST1224. Gene sequencing showed that the kpn1343 (ST37) strain harbored 12 resistance genes (OXA-33, TEM-1, SHV-11, AAC (6')-IId, AAC (3)-IIa, AAC (6')-Ib-cr, catB3, arr-3, sul1, oqxB, oqxA, CRP, and catB3) and included 15 genomic islands and 205 reduced virulence genes. The kpn1344 (ST3006) strain harbored 4 antibiotic-resistant genes (TEM-1, CTX-M-3, vgaC, and CRP) and included 19 genomic islands and 209 reduced virulence genes. MLST and PFGE showed that 15 strains of K. pneumoniae were divided into 3 groups with a high level of homology. ST1224 (kpn1362) was isolated on June 28, 2017, which was 10 days after the last isolate (kpn1359, June 18, 2017); thus, we speculated that ST1224 was not the clone that caused the outbreak.This co-outbreak of K. pneumoniae involved 2 clones: ST37 and ST3006. ST37 carried the multidrug-resistant genes, such as OXA-33, TEM-1, and SHV-11, and ST3006 was a novel K. pneumoniae ST typing. Whole-genome sequencing may be an effective method for screening bacterial-resistant genes and their functions.
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Affiliation(s)
- Dongjie Chen
- Shengli Clinical Medical College of Fujian Medical University
| | - Xinlan Hu
- Clinical Microbiology Laboratory, Fujian Provincial Hospital
| | - Falin Chen
- Clinical Microbiology Laboratory, Fujian Provincial Hospital
| | - Hongru Li
- Department of Respiratory Medicine and Critical Care Medicine, Fujian Provincial Hospital, Fuzhou, China
| | - Daxuan Wang
- Department of Respiratory Medicine and Critical Care Medicine, Fujian Provincial Hospital, Fuzhou, China
| | - Xiaoqin Li
- Department of Respiratory Medicine and Critical Care Medicine, Fujian Provincial Hospital, Fuzhou, China
| | - Changsheng Wu
- Clinical Microbiology Laboratory, Fujian Provincial Hospital
| | - Ning Li
- Clinical Microbiology Laboratory, Fujian Provincial Hospital
| | - Shaolian Wu
- Clinical Microbiology Laboratory, Fujian Provincial Hospital
| | - Zhen Li
- Clinical Microbiology Laboratory, Fujian Provincial Hospital
| | - Liqing Chen
- Clinical Microbiology Laboratory, Fujian Provincial Hospital
| | - Yusheng Chen
- Shengli Clinical Medical College of Fujian Medical University
- Department of Respiratory Medicine and Critical Care Medicine, Fujian Provincial Hospital, Fuzhou, China
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