Hospital-Onset MRSA Bacteremia Rates Are Significantly Correlated With Sociodemographic Factors: A Step Toward Risk Adjustment

Etiology and utility of hospital-onset bacteremia as a safety metric for targeted harm reduction

BACKGROUND

Hospital acquired infections (HAIs) are a major driver of morbidity and cost in health systems. Central line-associated bloodstream infections (CLABSIs) require intensive surveillance and review. All-cause hospital-onset bacteremia (HOB) may be a simpler reporting metric, correlates with CLABSI, and is viewed positively by HAI experts. Despite the ease in the collection, the proportion of HOBs that are actionable and preventable is unknown. Moreover, quality improvement strategies targeting it may be more challenging. In this study, we describe the bedside provider-perceived sources of HOB in order to provide insight into this new metric as a target for HAI prevention.

METHODS

All cases of HOBs in 2019 from an academic tertiary care hospital were retrospectively reviewed. Information was collected to assess provider-perceived etiology and associated clinical factors (microbiology, severity, mortality, and management). HOB was categorized as preventable or not preventable based on the perceived source from the care team and management decisions. Preventable causes included device-associated bacteremias, pneumonias, surgical complications, and contaminated blood cultures.

RESULTS

Of the 392 instances of HOB, 56.0% (n = 220) had episodes that were determined not preventable by providers. Excluding blood culture contaminates, the most common cause of preventable HOB was secondary to CLABSIs (9.9%, n = 39). Of the HOBs that were not preventable, the most common sources were gastrointestinal and abdominal (n = 62), neutropenic translocation (n = 37), and endocarditis (n = 23). Patients with HOB were generally medically complex with an average Charlson comorbidity index of 4.97. This translated into a higher average length of stay (29.23 vs 7.56, P < .001) and higher inpatient mortality (odds ratio 8.3, confidence interval [6.32-10.77]) when compared to admissions without HOB.

CONCLUSIONS

The majority of HOBs were not preventable and the HOB metric may be a marker of a sicker patient population making it a less actionable target for quality improvement. Standardization across the patient mix is important if the metric becomes linked to reimbursement. If the HOB metric were to be used in lieu of CLABSI, large tertiary care health systems that house sicker patients may be unfairly financially penalized for caring for more medically complex patients.

Is neighborhood deprivation index a risk factor for Staphylococcus aureus infections?

BACKGROUND

We assessed the association between neighborhood area deprivation index (ADI) and community-onset (co) and hospital-onset (ho) Staphylococcus aureus infection.

METHODS

Demographic and clinical characteristics of patients admitted to 5 adult hospitals in the mid-Atlantic between 2016 and 2018 were obtained. The association of ADI with methicillin-resistant (MRSA) and methicillin-sensitive (MSSA) S aureus infections was assessed using logistic regression models adjusting for severity of illness and days of admission.

RESULTS

Overall, increasing ADI was associated with higher odds of co- and ho-MRSA and MSSA infection. In univariate analysis, Black race was associated with 44% greater odds of ho-MRSA infection (odds ratio [OR] 1.44; 95% CI 1.18-1.76) and Asian race (co-MRSA OR 0.355; Confidence Interval (CI) 0.240-0.525; co-MSSA OR 0.718; CI 0.557-0.928) and unknown race (co-MRSA OR 0.470; CI 0.365-0.606; co-MSSA OR 0.699; CI 0.577-0.848) was associated with lower odds of co-MSSA and co-MRSA infections. When both race and ADI were included in the model, Black race was no longer associated with ho-MRSA infections whereas Asian and unknown race remained associated with lower odds of co-MRSA and co-MSSA infection. In the multivariable logistic regression, ADI was consistently associated with increased odds of S aureus infection (co-MRSA OR 1.132; CI 1.064-1.205; co-MSSA OR 1.089; CI 1.030-1.15; ho-MRSA OR 1.29; CI 1.16-1.43: ho-MSSA OR 1.215; CI 1.096-1.346).

CONCLUSIONS

The area deprivation index is associated with community and hospital-onset MRSA and MSSA infections.

Linking Sepsis with chronic arterial hypertension, diabetes mellitus, and socioeconomic factors in the United States: A scoping review

RATIONALE

Sepsis is a syndrome of life-threatening organ dysfunction caused by a dysregulated host immune response to infection. Social risk factors including location and poverty are associated with sepsis-related disparities. Understanding the social and biological phenotypes linked with the incidence of sepsis is warranted to identify the most at-risk populations. We aim to examine how factors in disadvantage influence health disparities related to sepsis.

METHODS

A scoping review was performed for English-language articles published in the United States from 1990 to 2022 on PubMed, Web of Science, and Scopus. Of the 2064 articles found, 139 met eligibility criteria and were included for review.

RESULTS

There is consistency across the literature of disproportionately higher rates of sepsis incidence, mortality, readmissions, and associated complications, in neighborhoods with socioeconomic disadvantage and significant poverty. Chronic arterial hypertension and diabetes mellitus also occur more frequently in the same geographic distribution as sepsis, suggesting a potential shared pathophysiology.

CONCLUSIONS

The distribution of chronic arterial hypertension, diabetes mellitus, social risk factors associated with socioeconomic disadvantage, and sepsis incidence, are clustered in specific geographical areas and linked by endothelial dysfunction. Such population factors can be utilized to create equitable interventions aimed at mitigating sepsis incidence and sepsis-related disparities.

Racial/Ethnic Inequities in Healthcare-associated Infections Under the Shadow of Structural Racism: Narrative Review and Call to Action

Purpose of Review

The purpose of this study is to review racial and ethnic inequities in the incidence and prevention of healthcare-associated infections (HAIs) in the USA, identify gaps in the literature, and recommend future directions to mitigate these inequities.

Recent Findings

While some existing literature has identified the presence of racial/ethnic inequities in HAI incidence and outcomes, few studies to date have evaluated whether HAI prevention efforts have mitigated these inequities. Factors contributing to inequities in HAI prevention may include unconscious bias of healthcare professionals towards minoritized patients; socioeconomic and structural inequities disparately affecting minoritized communities; the racial segregation of quality healthcare through hospital price discrimination; divergent reimbursement rates between public and private insurers; policies or performance metrics which underfund and financially penalize safety-net hospitals; and insufficient research evaluating and addressing HAI inequities.

Summary

Expansion of the literature is needed to further interrogate root causes and evaluate the impact of interventions on racial/ethnic inequities in HAI incidence. Measures to mitigate inequities might include teaching healthcare workers how to recognize and mitigate unconscious biases, expanding community resources which address the social and structural determinants of health, increasing access to preventive health services, reforming federal and institutional policies to better support safety-net hospitals and disincentivize price discrimination, and improving diversity and inclusion within the health workforce.