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White AT, Vaughn VM, Petty LA, Gandhi TN, Horowitz JK, Flanders SA, Bernstein SJ, Hofer TP, Ratz D, McLaughlin ES, Nielsen D, Czilok T, Minock J, Gupta A. Development of Patient Safety Measures to Identify Inappropriate Diagnosis of Common Infections. Clin Infect Dis 2024; 78:1403-1411. [PMID: 38298158 PMCID: PMC11175682 DOI: 10.1093/cid/ciae044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 12/28/2023] [Accepted: 01/26/2024] [Indexed: 02/02/2024] Open
Abstract
BACKGROUND Inappropriate diagnosis of infections results in antibiotic overuse and may delay diagnosis of underlying conditions. Here we describe the development and characteristics of 2 safety measures of inappropriate diagnosis of urinary tract infection (UTI) and community-acquired pneumonia (CAP), the most common inpatient infections on general medicine services. METHODS Measures were developed from guidelines and literature and adapted based on data from patients hospitalized with UTI and CAP in 49 Michigan hospitals and feedback from end-users, a technical expert panel (TEP), and a patient focus group. Each measure was assessed for reliability, validity, feasibility, and usability. RESULTS Two measures, now endorsed by the National Quality Forum (NQF), were developed. Measure reliability (derived from 24 483 patients) was excellent (0.90 for UTI; 0.91 for CAP). Both measures had strong validity demonstrated through (a) face validity by hospital users, the TEPs, and patient focus group, (b) implicit case review (ĸ 0.72 for UTI; ĸ 0.72 for CAP), and (c) rare case misclassification (4% for UTI; 0% for CAP) due to data errors (<2% for UTI; 6.3% for CAP). Measure implementation through hospital peer comparison in Michigan hospitals (2017 to 2020) demonstrated significant decreases in inappropriate diagnosis of UTI and CAP (37% and 32%, respectively, P < .001), supporting usability. CONCLUSIONS We developed highly reliable, valid, and usable measures of inappropriate diagnosis of UTI and CAP for hospitalized patients. Hospitals seeking to improve diagnostic safety, antibiotic use, and patient care should consider using these measures to reduce inappropriate diagnosis of CAP and UTI.
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Affiliation(s)
- Andrea T White
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Valerie M Vaughn
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Division of Health System Innovation & Research, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Division of Hospital Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Lindsay A Petty
- Division of Infectious Diseases, Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Tejal N Gandhi
- Division of Infectious Diseases, Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Jennifer K Horowitz
- Division of Hospital Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Scott A Flanders
- Division of Hospital Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Steven J Bernstein
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Health System, Ann Arbor, Michigan, USA
- Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Division of General Internal Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Timothy P Hofer
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Health System, Ann Arbor, Michigan, USA
- Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Division of General Internal Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - David Ratz
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Health System, Ann Arbor, Michigan, USA
| | - Elizabeth S McLaughlin
- Division of Hospital Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Daniel Nielsen
- Division of Hospital Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Tawny Czilok
- Division of Hospital Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Jennifer Minock
- Division of Hospital Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Ashwin Gupta
- Division of Hospital Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
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Livorsi DJ, Branch-Elliman W, Drekonja D, Echevarria KL, Fitzpatrick MA, Goetz MB, Graber CJ, Jones MM, Kelly AA, Madaras-Kelly K, Morgan DJ, Stevens VW, Suda K, Trautner BW, Ward MJ, Jump RLP. Research agenda for antibiotic stewardship within the Veterans' Health Administration, 2024-2028. Infect Control Hosp Epidemiol 2024:1-7. [PMID: 38305034 DOI: 10.1017/ice.2024.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Affiliation(s)
- Daniel J Livorsi
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans' Affairs (VA) Health Care System, Iowa City, Iowa
- Division of Infectious Diseases, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Westyn Branch-Elliman
- VA Boston Healthcare System, Department of Medicine, Section of Infectious Diseases. Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Dimitri Drekonja
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Kelly L Echevarria
- VHA Pharmacy Benefits and Antimicrobial Stewardship Task Force, Department of Veterans' Affairs, Washington, DC
| | - Margaret A Fitzpatrick
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Healthcare System, Aurora, Colorado
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Matthew Bidwell Goetz
- VA Greater Los Angeles Healthcare System, Los Angeles, California
- David Geffen School of Medicine at the University of California, Los Angeles, California
| | - Christopher J Graber
- VA Greater Los Angeles Healthcare System, Los Angeles, California
- David Geffen School of Medicine at the University of California, Los Angeles, California
| | - Makoto M Jones
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Allison A Kelly
- VHA Pharmacy Benefits and Antimicrobial Stewardship Task Force, Department of Veterans' Affairs, Washington, DC
- Cincinnati Veterans' Affairs Medical Center, Cincinnati, Ohio
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Karl Madaras-Kelly
- Boise Veterans' Affairs Medical Center, Boise, Idaho
- Idaho State University, College of Pharmacy, Meridian, Idaho
| | - Daniel J Morgan
- Department of Medicine, VA Maryland Healthcare System, Baltimore, Maryland
- Center for Innovation in Diagnosis, University of Maryland School of Medicine, Baltimore, Maryland
| | - Vanessa W Stevens
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Katie Suda
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Barbara W Trautner
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans' Affairs Medical Center, Houston, Texas
- Section of Health Services Research, Baylor College of Medicine, Houston, Texas
| | - Michael J Ward
- Geriatric Research, Education, and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee
- Department of Emergency Medicine and Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robin L P Jump
- Technology Enhancing Cognition and Health Geriatric Research Education and Clinical Center (TECH-GRECC) at the VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of Geriatric Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Hibbert PD, Molloy CJ, Cameron ID, Gray LC, Reed RL, Wiles LK, Westbrook J, Arnolda G, Bilton R, Ash R, Georgiou A, Kitson A, Hughes CF, Gordon SJ, Mitchell RJ, Rapport F, Estabrooks C, Alexander GL, Vincent C, Edwards A, Carson-Stevens A, Wagner C, McCormack B, Braithwaite J. The quality of care delivered to residents in long-term care in Australia: an indicator-based review of resident records (CareTrack Aged study). BMC Med 2024; 22:22. [PMID: 38254113 PMCID: PMC10804560 DOI: 10.1186/s12916-023-03224-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 12/12/2023] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND This study estimated the prevalence of evidence-based care received by a population-based sample of Australian residents in long-term care (LTC) aged ≥ 65 years in 2021, measured by adherence to clinical practice guideline (CPG) recommendations. METHODS Sixteen conditions/processes of care amendable to estimating evidence-based care at a population level were identified from prevalence data and CPGs. Candidate recommendations (n = 5609) were extracted from 139 CPGs which were converted to indicators. National experts in each condition rated the indicators via the RAND-UCLA Delphi process. For the 16 conditions, 236 evidence-based care indicators were ratified. A multi-stage sampling of LTC facilities and residents was undertaken. Trained aged-care nurses then undertook manual structured record reviews of care delivered between 1 March and 31 May 2021 (our record review period) to assess adherence with the indicators. RESULTS Care received by 294 residents with 27,585 care encounters in 25 LTC facilities was evaluated. Residents received care for one to thirteen separate clinical conditions/processes of care (median = 10, mean = 9.7). Adherence to evidence-based care indicators was estimated at 53.2% (95% CI: 48.6, 57.7) ranging from a high of 81.3% (95% CI: 75.6, 86.3) for Bladder and Bowel to a low of 12.2% (95% CI: 1.6, 36.8) for Depression. Six conditions (skin integrity, end-of-life care, infection, sleep, medication, and depression) had less than 50% adherence with indicators. CONCLUSIONS This is the first study of adherence to evidence-based care for people in LTC using multiple conditions and a standardised method. Vulnerable older people are not receiving evidence-based care for many physical problems, nor care to support their mental health nor for end-of-life care. The six conditions in which adherence with indicators was less than 50% could be the focus of improvement efforts.
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Affiliation(s)
- Peter D Hibbert
- Australian Institute of Health Innovation, Macquarie University, 75 Talavera Rd, North Ryde, Sydney, NSW, 2109, Australia.
- IIMPACT in Health, Allied Health and Human Performance, University of South Australia, North Terrace, Adelaide, SA, 5000, Australia.
- South Australian Health and Medical Research Institute, North Terrace, Adelaide, SA, 5000, Australia.
| | - Charlotte J Molloy
- Australian Institute of Health Innovation, Macquarie University, 75 Talavera Rd, North Ryde, Sydney, NSW, 2109, Australia
- IIMPACT in Health, Allied Health and Human Performance, University of South Australia, North Terrace, Adelaide, SA, 5000, Australia
- South Australian Health and Medical Research Institute, North Terrace, Adelaide, SA, 5000, Australia
| | - Ian D Cameron
- John Walsh Centre for Rehabilitation Research, Northern Sydney Local Health District, Faculty of Medicine and Health, University of Sydney, Kolling Institute, Reserve Rd, St Leonards, NSW, 2065, Australia
| | - Leonard C Gray
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Princess Alexandra Hospital Campus, Woolloongabba, QLD, 4102, Australia
| | - Richard L Reed
- Discipline of General Practice, College of Medicine and Public Health, Flinders University, Sturt Rd, Bedford Park, SA, 5042, Australia
| | - Louise K Wiles
- Australian Institute of Health Innovation, Macquarie University, 75 Talavera Rd, North Ryde, Sydney, NSW, 2109, Australia
- IIMPACT in Health, Allied Health and Human Performance, University of South Australia, North Terrace, Adelaide, SA, 5000, Australia
| | - Johanna Westbrook
- Australian Institute of Health Innovation, Macquarie University, 75 Talavera Rd, North Ryde, Sydney, NSW, 2109, Australia
| | - Gaston Arnolda
- Australian Institute of Health Innovation, Macquarie University, 75 Talavera Rd, North Ryde, Sydney, NSW, 2109, Australia
| | - Rebecca Bilton
- Australian Institute of Health Innovation, Macquarie University, 75 Talavera Rd, North Ryde, Sydney, NSW, 2109, Australia
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Sturt Rd, Bedford Park, SA, 5042, Australia
| | - Ruby Ash
- Australian Institute of Health Innovation, Macquarie University, 75 Talavera Rd, North Ryde, Sydney, NSW, 2109, Australia
| | - Andrew Georgiou
- Australian Institute of Health Innovation, Macquarie University, 75 Talavera Rd, North Ryde, Sydney, NSW, 2109, Australia
| | - Alison Kitson
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Sturt Rd, Bedford Park, SA, 5042, Australia
| | - Clifford F Hughes
- Australian Institute of Health Innovation, Macquarie University, 75 Talavera Rd, North Ryde, Sydney, NSW, 2109, Australia
| | - Susan J Gordon
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Sturt Rd, Bedford Park, SA, 5042, Australia
| | - Rebecca J Mitchell
- Australian Institute of Health Innovation, Macquarie University, 75 Talavera Rd, North Ryde, Sydney, NSW, 2109, Australia
| | - Frances Rapport
- Australian Institute of Health Innovation, Macquarie University, 75 Talavera Rd, North Ryde, Sydney, NSW, 2109, Australia
| | - Carole Estabrooks
- Faculty of Nursing, University of Alberta, Edmonton Clinic Health Academy, 11405-87 Avenue, Edmonton, AB, T6G 1C9, Canada
| | | | - Charles Vincent
- Department of Experimental Psychology, Radcliffe Observatory, University of Oxford, Woodstock Road, Oxford, OX2 6GG, England, UK
| | - Adrian Edwards
- PRIME Centre Wales & Division of Population Medicine, Cardiff University, 8Th Floor Neuadd Meirionnydd, Heath Park, Cardiff, Wales, CF14 4YS, UK
| | - Andrew Carson-Stevens
- PRIME Centre Wales & Division of Population Medicine, Cardiff University, 8Th Floor Neuadd Meirionnydd, Heath Park, Cardiff, Wales, CF14 4YS, UK
| | - Cordula Wagner
- Netherlands Institute for Health Services Research, Otterstraat 118, Utrecht, 3513 CR, The Netherlands
- Amsterdam University Medical Center/VU University, Van Der Boechorststraat 7, 1081 HV, Amsterdam, The Netherlands
| | - Brendan McCormack
- The Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, City Road, Sydney, NSW, 2006, Australia
| | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Macquarie University, 75 Talavera Rd, North Ryde, Sydney, NSW, 2109, Australia
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Riester MR, Douglas CM, Silva JB, Datta R, Zullo AR. Clinicians who primarily practice in nursing homes and outcomes among residents with urinary tract infection or pneumonia. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e253. [PMID: 38178878 PMCID: PMC10762639 DOI: 10.1017/ash.2023.527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 12/06/2023] [Accepted: 12/08/2023] [Indexed: 01/06/2024]
Abstract
Objective Assess the association between clinicians who primarily practice in nursing homes (NHs) and 14-day resident outcomes following initial antibiotic dispensing for pneumonia or urinary tract infection (UTI). Design Retrospective cohort. Setting U.S. NHs. Participants NH residents aged ≥65 years who were prescribed antibiotics for pneumonia or UTI between 1 January 2016 and 30 November 2018. Methods Medicare fee-for-service claims were linked to Minimum Data Set data. Clinicians who primarily practiced in NHs prescribed ≥90% of Part D dispensings to NH residents. Outcomes included death, all-cause and infection-specific hospitalization, and subsequent antibiotic dispensing. Adjusted risk ratios were estimated using inverse-probability-of-treatment-weighted (IPTW) modified Poisson regression models adjusting for 53 covariates. Results The study population included 28,826 resident-years who were prescribed antibiotics for pneumonia and 106,354 resident-years who were prescribed antibiotics for UTI. Among the pneumonia group, clinicians who primarily practiced in NHs were associated with a greater risk of death (RR 1.3; 95%CLs 1.0, 1.6), lower risks of all-cause (RR 0.9; 95%CLs 0.8, 0.9) and infection-specific hospitalization (RR 0.8; 95%CLs 0.7, 0.9), and similar risk of subsequent antibiotic dispensing (RR 1.0; 95%CLs 1.0, 1.1) after IPTW. No meaningful associations were observed between clinicians who primarily practiced in NHs and outcomes among the UTI group. Conclusions Clinicians who primarily practiced in NHs were associated with a lower risk of hospitalization but greater risk of mortality for NH residents with pneumonia. Further examination is needed to better understand drivers of differences in infection-related outcomes based on clinicians' training and primary practice setting.
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Affiliation(s)
- Melissa R. Riester
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Cody M. Douglas
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Joe B.B. Silva
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Rupak Datta
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Andrew R. Zullo
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
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van Eijk J, Rutten JJS, Hertogh CMPM, Smalbrugge M, van Buul LW. Observation of urinary tract infection signs and symptoms in nursing home residents with impaired awareness or ability to communicate signs and symptoms: The development of supportive tools. Int J Older People Nurs 2023; 18:e12560. [PMID: 37563799 DOI: 10.1111/opn.12560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 05/24/2023] [Accepted: 07/08/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Antibiotics are often inappropriately prescribed for urinary tract infections (UTIs) in nursing home (NH) residents. Research emphasises the importance of prescribing antibiotics only if there are UTI-related signs and symptoms (S&S). However, for many NH residents it is challenging to find out whether such S&S are present, for example due to cognitive disorders. OBJECTIVES To provide insight into the assessment of UTI-related S&S in NH residents with impaired awareness or ability to communicate S&S, and to develop supportive tools for the observation of UTI-related S&S in this subgroup of NH residents, by nursing staff. METHODS We performed a practice-based study using mixed methods. Data of 295 cases of suspected UTI were analysed to determine how often UTI-related S&S were 'not assessed/non-assessable' in residents with and without dementia. Barriers and facilitators in observing UTI-related S&S in NH residents with impaired awareness or ability to communicate S&S were derived from interviews and focus groups with nursing staff. Literature review, focus group data, additional telephone interviews and questionnaires with nursing staff were used in a step-by-step process, including pilot testing, to develop supportive tools for the observation of UTI-related S&S. RESULTS UTI-related S&S were assessable in the majority of NH residents with dementia. The proportion 'not assessed/non-assessable' S&S in residents with dementia increased with increasing severity of dementia. In residents with very severe dementia, up to 58% of the S&S were 'not assessed/non-assessable'. Knowing the resident, working methodologically, and being sufficiently skilled to interpret observations in residents facilitate the assessment of UTI-related S&S. Insights acquired during the different study elements resulted in the development of an observation checklist and a 24-h observation tool. CONCLUSIONS The more NH residents have impaired awareness of ability to communicate S&S, the more difficult it seems to be to assess UTI-related S&S. The observation checklist and 24-h observation tool developed in the current study may support nursing staff in their observation of UTI-related S&S in this group of NH residents.
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Affiliation(s)
- Jorna van Eijk
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Jeanine J S Rutten
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Cees M P M Hertogh
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Martin Smalbrugge
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Laura W van Buul
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, The Netherlands
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Liu Z, Yu X, Zhou Z, Zhou J, Shuai X, Lin Z, Chen H. 3D ZnO/Activated Carbon Alginate Beads for the Removal of Antibiotic-Resistant Bacteria and Antibiotic Resistance Genes. Polymers (Basel) 2023; 15:polym15092215. [PMID: 37177361 PMCID: PMC10180892 DOI: 10.3390/polym15092215] [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: 04/23/2023] [Revised: 05/06/2023] [Accepted: 05/06/2023] [Indexed: 05/15/2023] Open
Abstract
The worldwide prevalence of antibiotic-resistant bacteria (ARB) and antibiotic resistance genes (ARGs) have become one of the most urgent issues for public health. Thus, it is critical to explore more sustainable methods with less toxicity for the long-term removal of both ARB and ARGs. In this study, we fabricated a novel material by encapsulating zinc oxide (ZnO) nanoflowers and activated carbon (AC) in an alginate biopolymer. When the dosage of ZnO was 1.0 g (≈2 g/L), the composite beads exhibited higher removal efficiency and a slight release of Zn2+ in water treatment. Fixed bed column experiments demonstrated that ZnO/AC alginate beads had excellent removal capacities. When the flow rate was 1 mL/min, and the initial concentration was 107 CFU/mL, the removal efficiency of ARB was 5.69-log, and the absolute abundance of ARGs was decreased by 2.44-2.74-log. Moreover, the mechanism demonstrated that ZnO significantly caused cell lysis, cytoplasmic leakage, and the increase of reactive oxygen species induced subsequent oxidative stress state. These findings suggested that ZnO/AC alginate beads can be a promising material for removing ARB and ARGs from wastewater with eco-friendly and sustainable properties.
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Affiliation(s)
- Zhe Liu
- College of Environmental and Resource Sciences, Zhejiang University, Hangzhou 310058, China
| | - Xi Yu
- College of Environmental and Resource Sciences, Zhejiang University, Hangzhou 310058, China
| | - Zhenchao Zhou
- College of Environmental and Resource Sciences, Zhejiang University, Hangzhou 310058, China
| | - Jinyu Zhou
- College of Environmental and Resource Sciences, Zhejiang University, Hangzhou 310058, China
| | - Xinyi Shuai
- College of Environmental and Resource Sciences, Zhejiang University, Hangzhou 310058, China
| | - Zejun Lin
- College of Environmental and Resource Sciences, Zhejiang University, Hangzhou 310058, China
| | - Hong Chen
- College of Environmental and Resource Sciences, Zhejiang University, Hangzhou 310058, China
- International Cooperation Base of Environmental Pollution and Ecological Health, Science and Technology Agency of Zhejiang, Zhejiang University, Hangzhou 310058, China
- Key Laboratory of Environment Remediation and Ecological Health, Ministry of Education, College of Environmental Resource Sciences, Zhejiang University, Hangzhou 310058, China
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7
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Bacteriuria in older adults triggers confusion in healthcare providers: A mindful pause to treat the worry. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e4. [PMID: 36714291 PMCID: PMC9879885 DOI: 10.1017/ash.2022.343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 10/31/2022] [Indexed: 01/11/2023]
Abstract
The evidence base for refraining from screening for or treating asymptomatic bacteriuria (ASB) in older adults is strong, but both practices remain prevalent. Clinical confusion over how to respond to a change from baseline, when to order a urinalysis and urine culture, and what to do with a positive urine culture fuels unnecessary antibiotic use for ASB. If the provider can take a mindful pause to apply evidenced-based assessment tools, the resulting increased clarity in how to manage the situation can reduce overtreatment of ASB.
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8
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Appropriateness of antibiotic use in patients with and without altered mental status diagnosed with a urinary tract infection. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e198. [PMID: 36712472 PMCID: PMC9879859 DOI: 10.1017/ash.2022.346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 11/02/2022] [Accepted: 11/03/2022] [Indexed: 12/15/2022]
Abstract
Objective The objective of this study was to determine antibiotic appropriateness based on Loeb minimum criteria (LMC) in patients with and without altered mental status (AMS). Design Retrospective, quasi-experimental study assessing pooled data from 3 periods pertaining to the implementation of a UTI management guideline. Setting Academic medical center in Lexington, Kentucky. Patients Adult patients aged ≥18 years with a collected urinalysis receiving antimicrobial therapy for a UTI indication. Methods Appropriateness of UTI management was assessed in patients prior to an institutional UTI guideline, after guideline introduction and education, and after implementation of a prospective audit-and-feedback stewardship intervention from September to November 2017-2019. Patient data were pooled and compared between patients noted to have AMS versus those with classic UTI symptoms. Loeb minimum criteria were used to determine whether UTI diagnosis and treatment was warranted. Results In total, 600 patients were included in the study. AMS was one of the most common indications for testing across the 3 periods (19%-30.5%). Among those with AMS, 25 patients (16.7%) met LMC, significantly less than the 151 points (33.6%) without AMS (P < .001). Conclusions Patients with AMS are prescribed antibiotic therapy without symptoms indicative of UTI at a higher rate than those without AMS, according to LMC. Further antimicrobial stewardship efforts should focus on prescriber education and development of clearly defined criteria for patients with and without AMS.
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9
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Antibiotic postprescribing modification opportunities among nursing home residents treated for urinary tract infection. Infect Control Hosp Epidemiol 2022:1-6. [DOI: 10.1017/ice.2022.202] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Abstract
Objective:
To characterize opportunities to postprescriptively modify antibiotic prescriptions initiated for treatment of suspected urinary tract infection (UTI) in nursing homes.
Design:
Cross-sectional cohort study.
Methods:
Data from the health records of residents treated for UTI between 2013 and 2014 in 5 Wisconsin nursing homes were abstracted using a structured approach. Explicit definitions were used to identify whether the prescribed antibiotic could have been stopped, shortened, or changed to a nonfluoroquinolone alternative. Antibiotic treatments appropriately modified by study nursing home providers in real time were not considered modifiable. Identification of >1 potential modification opportunity (eg, stop and shorten) per antibiotic treatment event was permitted.
Results:
In total, 356 eligible antibiotic treatment courses among 249 unique residents were identified. Only 59 antibiotic courses prescribed for treatment of suspected UTI (16.6%) were not amenable to any modification. Discontinuation of treatment due to lack of signs or symptoms of infection was the most frequently identified potential modification opportunity (66.2%). Although less common, substantial numbers of antibiotic treatment courses were potentially amenable to shortening (34%) or agent change (19%) modifications. If applied in concert at 72 hours after antibiotic initiation, stop and shorten modifications could eradicate up to 1,326 avoidable antibiotic days, and change modifications could remove a 32 remaining avoidable fluoroquinolone days.
Conclusions:
Substantial opportunity exists to enhance the quality of antibiotic prescribing for treatment of suspected UTI in nursing homes through postprescriptive review interventions. Additional studies examining how to best design and implement postprescriptive review interventions in nursing homes are needed.
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Abstract
Community-acquired pneumonia is an important cause of morbidity and mortality. It can be caused by bacteria, viruses, or fungi and can be prevented through vaccination with pneumococcal, influenza, and COVID-19 vaccines. Diagnosis requires suggestive history and physical findings in conjunction with radiographic evidence of infiltrates. Laboratory testing can help guide therapy. Important issues in treatment include choosing the proper venue, timely initiation of the appropriate antibiotic or antiviral, appropriate respiratory support, deescalation after negative culture results, switching to oral therapy, and short treatment duration.
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Claeys KC, Trautner BW, Leekha S, Coffey KC, Crnich CJ, Diekema D, Fakih MG, Goetz MB, Gupta K, Jones MM, Leykum L, Liang SY, Pineles L, Pleiss A, Spivak ES, Suda KJ, Taylor J, Rhee C, Morgan DJ. Optimal Urine Culture Diagnostic Stewardship Practice- Results from an Expert Modified-Delphi Procedure. Clin Infect Dis 2021; 75:382-389. [PMID: 34849637 DOI: 10.1093/cid/ciab987] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Urine cultures are nonspecific for infection and often lead to misdiagnosis of urinary tract infection and unnecessary antibiotics. Diagnostic stewardship is a set of procedures that modifies test ordering, processing, and reporting in order to optimize diagnosis and downstream treatment. This study aimed to develop expert guidance on best practices for urine culture diagnostic stewardship. METHODS A RAND-modified Delphi approach with a multidisciplinary expert panel was used to ascertain diagnostic stewardship best practices. Clinical questions to guide recommendations were grouped in three thematic areas (ordering, processing, reporting) in practice settings of emergency department, inpatient, ambulatory, and long-term care. Fifteen experts ranked recommendations on a 9-point Likert scale. Recommendations on which the panel did not reach agreement were discussed in a virtual meeting, and a then second round of ranking by email was completed. After secondary review of results and panel discussion, a series of guidance statements was developed. RESULTS 165 questions were reviewed with the panel reaching agreement on 104, leading to 18 overarching guidance statements. The following strategies were recommended to optimize ordering urine cultures: requiring documentation of symptoms, alerts to discourage ordering in the absence of symptoms, and cancelling repeat cultures. For urine culture processing, conditional reflex urine cultures and urine white blood cell as criteria were supported. For urine culture reporting, appropriate practices included nudges to discourage treatment under specific conditions and selective reporting of antibiotics to guide therapy decisions. CONCLUSIONS These 18 guidance statements can optimize use of the imperfect urine culture for better patient outcomes.
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Affiliation(s)
- Kimberly C Claeys
- Infectious Diseases, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Barbara W Trautner
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX.,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Surbhi Leekha
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, University of Maryland Medical Center, Baltimore, MD, USA
| | - K C Coffey
- Associate Hospital Epidemiologist, VA Maryland Healthcare System, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Christopher J Crnich
- Chief of Medicine, Hospital Epidemiologist, William S. Middleton Memorial Veterans Hospital, Madison, WI, USA
| | - Dan Diekema
- Division of Infectious Diseases, University of Iowa Carver College of Medicine, University of Iowa Health Care, Iowa City, IA, USA
| | - Mohamad G Fakih
- Chief Quality Officer, Quality Department, Clinical & Network Services, Ascension Healthcare, Grosse Pointe Woods and Wayne State University School of Medicine, Detroit, MI, USA
| | - Matthew Bidwell Goetz
- Infectious Diseases Section, VA Greater Los Angeles Healthcare System, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Kalpana Gupta
- Associate Chief of Staff and Chief, Section of Infectious Diseases, VA Boston Healthcare System, of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Makoto M Jones
- Salt Lake City Veterans Affairs Healthcare System, Internal Medicine - Associate Professor, Division of Epidemiology, The University of Utah, Salt Lake City, UT, USA
| | - Luci Leykum
- Department of Internal Medicine, University of Texas at Austin Dell School of Medicine, Austin, TX, USA
| | - Stephen Y Liang
- Medicine, Division of Infectious Diseases, John T. Milliken Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Lisa Pineles
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ashley Pleiss
- Lead Clinical Nurse, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Emily S Spivak
- Co-Director of the Antimicrobial Stewardship, University of Utah Health and the Salt Lake City Veterans Affairs Healthcare System, Salt Lake City, UT, USA
| | - Katie J Suda
- VA Pittsburgh Healthcare System, Professor of Medicine, Division of General Internal Medicine, University of Pittsburgh and the, Pittsburgh, PA, USA
| | | | - Chanu Rhee
- Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Associate Hospital Epidemiologist, Brigham and Women's Hospital, Boston, MA, USA
| | - Daniel J Morgan
- Chief Hospital, VA Maryland Healthcare System, Epidemiologist Department of Epidemiology, University of Maryland School of Medicine, Baltimore, MD, USA
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12
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Bej T, Kothadia S, Wilson BM, Song S, Briggs JM, Banks RE, Donskey CJ, Perez F, Jump RLP. Impact of fever thresholds in detection of COVID-19 in Department of Veterans Affairs Community Living Center residents. J Am Geriatr Soc 2021; 69:3044-3050. [PMID: 34375443 PMCID: PMC8447344 DOI: 10.1111/jgs.17415] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 07/23/2021] [Accepted: 07/31/2021] [Indexed: 11/29/2022]
Abstract
Background Among nursing home residents, for whom age and frailty can blunt febrile responses to illness, the temperature used to define fever can influence the clinical recognition of COVID‐19 symptoms. To assess the potential for differences in the definition of fever to characterize nursing home residents with COVID‐19 infections as symptomatic, pre‐symptomatic, or asymptomatic, we conducted a retrospective study on a national cohort of Department of Veterans Affairs (VA) Community Living Center (CLC) residents tested for SARS‐CoV‐2. Methods Residents with positive SARS‐CoV‐2 tests were classified as asymptomatic if they did not experience any symptoms, and as symptomatic or pre‐symptomatic if the experienced a fever (>100.4°F) before or following a positive SARS‐CoV‐2 test, respectively. All‐cause 30‐day mortality was assessed as was the influence of a lower temperature threshold (>99.0°F) on classification of residents with positive SARS‐CoV‐2 tests. Results From March 2020 through November 2020, VA CLCs tested 11,908 residents for SARS‐CoV‐2 using RT‐PCR, with a positivity of rate of 13% (1557). Among residents with positive tests and using >100.4°F, 321 (21%) were symptomatic, 425 (27%) were pre‐symptomatic, and 811 (52%) were asymptomatic. All‐cause 30‐day mortality among residents with symptomatic and pre‐symptomatic COVID‐19 infections was 24% and 26%, respectively, while those with an asymptomatic infection had mortality rates similar to residents with negative SAR‐CoV‐2 tests (10% and 5%, respectively). Using >99.0°F would have increased the number of residents categorized as symptomatic at the time of testing from 321 to 773. Conclusions All‐cause 30‐day mortality was similar among VA CLC residents with symptomatic or pre‐symptomatic COVID‐19 infection, and lower than rates reported in non‐VA nursing homes. A lower temperature threshold would increase the number of residents recognized as having symptomatic infection, potentially leading to earlier detection and more rapid implementation of therapeutic interventions and infection prevention and control measures.
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Affiliation(s)
- Taissa Bej
- Geriatric Research Education and Clinical Center (GRECC), VA Northeast Ohio Healthcare System, Cleveland, Ohio, USA
| | - Sonya Kothadia
- Division of Infectious Diseases & HIV Medicine in the Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Brigid M Wilson
- Geriatric Research Education and Clinical Center (GRECC), VA Northeast Ohio Healthcare System, Cleveland, Ohio, USA.,Division of Infectious Diseases & HIV Medicine in the Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Sunah Song
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Cleveland Institute for Computational Biology, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Janet M Briggs
- Geriatric Research Education and Clinical Center (GRECC), VA Northeast Ohio Healthcare System, Cleveland, Ohio, USA
| | - Richard E Banks
- Geriatric Research Education and Clinical Center (GRECC), VA Northeast Ohio Healthcare System, Cleveland, Ohio, USA
| | - Curtis J Donskey
- Geriatric Research Education and Clinical Center (GRECC), VA Northeast Ohio Healthcare System, Cleveland, Ohio, USA.,Division of Infectious Diseases & HIV Medicine in the Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Federico Perez
- Geriatric Research Education and Clinical Center (GRECC), VA Northeast Ohio Healthcare System, Cleveland, Ohio, USA.,Division of Infectious Diseases & HIV Medicine in the Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Robin L P Jump
- Geriatric Research Education and Clinical Center (GRECC), VA Northeast Ohio Healthcare System, Cleveland, Ohio, USA.,Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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Comparison of criteria for determining appropriateness of antibiotic prescribing in nursing homes. Infect Control Hosp Epidemiol 2021; 43:860-863. [PMID: 34162459 DOI: 10.1017/ice.2021.221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Measuring the appropriateness of antibiotic prescribing in nursing homes remains a challenge. The revised McGeer criteria, which are widely used to conduct infection surveillance in nursing homes, were not designed to assess antibiotic appropriateness. The Loeb criteria were explicitly designed for this purpose but are infrequently used outside investigational studies. The extent to which the revised McGeer and Loeb criteria overlap and can be used interchangeably for tracking antibiotic appropriateness in nursing homes remains insufficiently studied. METHODS We conducted a cross-sectional chart review study in 5 Wisconsin nursing homes and applied the revised McGeer and Loeb criteria to all nursing home-initiated antibiotic treatment courses. Kappa (κ) statistics were employed to assess level of agreement overall and by treatment indications. RESULTS Overall, 734 eligible antibiotic courses were initiated in participating nursing homes during the study period. Of 734 antibiotic courses, 372 (51%) satisfied the Loeb criteria, while only 211 (29%) of 734 satisfied the revised McGeer criteria. Only 169 (23%) of 734 antibiotic courses satisfied both criteria, and the overall level of agreement between them was fair (κ = 0.35). When stratified by infection type, levels of agreement between the revised McGeer and Loeb criteria were moderate for urinary tract infections (κ = 0.45), fair for skin and soft-tissue infections (0.36), and slight for respiratory tract infections (0.17). CONCLUSIONS Agreement between the revised McGeer and Loeb criteria is limited, and nursing homes should employ the revised McGeer and Loeb criteria for their intended purposes. Studies to establish the best method for ongoing monitoring of antibiotic appropriateness in nursing homes are needed.
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Cassone M, Mody L. Measuring the outsized impact of COVID-19 in the evolving setting of aged care facilities. EClinicalMedicine 2021; 34:100825. [PMID: 33880439 PMCID: PMC8050616 DOI: 10.1016/j.eclinm.2021.100825] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 03/19/2021] [Indexed: 01/24/2023] Open
Affiliation(s)
- Marco Cassone
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Lona Mody
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
- Geriatric Research and Education Clinical Center, VA Ann Arbor, MI, USA
- Corresponding author. Present address: Division of Geriatric and Palliative Medicine, University of Michigan Medical School, 300 N Ingalls Rd, Room 905, Ann Arbor, MI 48109, USA.
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Wither proper evaluation of falls for coexisting systemic infections? Infect Control Hosp Epidemiol 2021; 43:668-669. [PMID: 33648618 DOI: 10.1017/ice.2021.56] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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