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Fitzpatrick MA, Nwafo N. Urinary Tract Infection Diagnostic and Management Considerations in People with Spinal Cord Injury and Neurogenic Bladder. Infect Dis Clin North Am 2024; 38:381-393. [PMID: 38580574 DOI: 10.1016/j.idc.2024.03.012] [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: 04/07/2024]
Abstract
Urinary tract infections (UTIs) are common complications in people with neurogenic bladder. Prevention, diagnosis, and treatment are challenging for several reasons, including a high prevalence of asymptomatic bacteriuria and catheter use, frequent ambiguous nonlocalizing signs and symptoms, increased risk for complications and difficult-to-treat pathogens, and a lack of effective preventative methods. Current research aims to improve elicitation and evaluation of signs and symptoms, implement algorithms to avoid urine cultures in asymptomatic patients and use appropriate antibiotics for UTI, and identify novel effective prevention methods.
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Affiliation(s)
- Margaret A Fitzpatrick
- Department of Medicine, Section of Infectious Diseases, VA Eastern Colorado Healthcare System, Aurora, CO, USA; Department of Medicine, Division of Infectious Diseases, University of Colorado Anschutz Medical Center, Aurora, CO, USA.
| | - Nnamdi Nwafo
- Department of Medicine, Division of Infectious Diseases, University of Colorado Anschutz Medical Center, CU Research Complex II, 12700 East 19th Avenue. Mail Stop B168, Aurora, CO 80045, USA
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Senthinathan A, Penner M, Tu K, Morris AM, Craven BC, Jaglal SB. Identifying prescribers of antibiotics in a primary care spinal cord injury cohort. Spinal Cord Ser Cases 2024; 10:3. [PMID: 38302448 PMCID: PMC10834400 DOI: 10.1038/s41394-024-00615-8] [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: 11/18/2022] [Revised: 01/19/2024] [Accepted: 01/22/2024] [Indexed: 02/03/2024] Open
Abstract
STUDY DESIGN A retrospective cross-sectional study. OBJECTIVE To identify who prescribes outpatient antibiotics among a primary care spinal cord injury (SCI) cohort. SETTING ICES databases in Ontario, Canada. METHODS A cohort of individuals with SCI were retrospectively identified using a tested-algorithm and chart reviews in a primary care electronic medical records database. The cohort was linked to a drug dispensing database to obtain outpatient antibiotic prescribing information, and prescriber details were obtained from a physician database. RESULTS Final cohort included three hundred and twenty individuals with SCI. The average annual number of antibiotic courses dispensed for the SCI cohort was 2.0 ± 6.2. For dispensed antibiotics, 58.9% were prescribed by rostered-primary care practice physicians, compared to 17.9% by emergency and non-rostered primary care physicians, 17.4% by specialists and 6.1% by non-physician prescribers. Those who lived in urban areas and rural areas, compared to those who lived in suburban areas, were more likely to receive antibiotics from emergency and non-rostered primary care physicians than from rostered-primary care practice physicians. CONCLUSION Although individuals with SCI received outpatient antibiotic prescriptions from multiple sources, physicians from an individual's rostered-primary care practice were the main antibiotic prescribers. As such, interventions to optimize antibiotics use in the SCI population should target the primary care practice.
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Affiliation(s)
- Arrani Senthinathan
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada.
- KITE (Knowledge Innovation Talent Everywhere), Toronto Rehabilitation Institute-University Health Network, Toronto, ON, Canada.
| | - Melanie Penner
- Bloorview Research Institute/Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON, Canada
- Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Karen Tu
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- North York General Hospital, Toronto, ON, Canada
- Toronto Western Family Health Team, University Health Network, Toronto, ON, Canada
| | - Andrew M Morris
- Antimicrobial Stewardship Program, University Health Network, Toronto, ON, Canada
- Department of Medicine, Division of Infectious Diseases, Sinai Health, University Health Network, and University of Toronto, Toronto, ON, Canada
| | - B Catharine Craven
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
- KITE (Knowledge Innovation Talent Everywhere), Toronto Rehabilitation Institute-University Health Network, Toronto, ON, Canada
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Spinal Cord Rehabilitation Program, Toronto Rehabilitation Institute-University Health Network, Toronto, ON, Canada
| | - Susan B Jaglal
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
- KITE (Knowledge Innovation Talent Everywhere), Toronto Rehabilitation Institute-University Health Network, Toronto, ON, Canada
- Rehabilitation Science Institute and Department of Physical Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
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Fitzpatrick MA, Wirth M, Burns SP, Suda KJ, Weaver FM, Collins E, Safdar N, Evans CT. Management of Asymptomatic Bacteriuria and Urinary Tract Infections in Patients With Neurogenic Bladder and Factors Associated With Inappropriate Diagnosis and Treatment. Arch Phys Med Rehabil 2024; 105:112-119. [PMID: 37827486 PMCID: PMC10841968 DOI: 10.1016/j.apmr.2023.09.023] [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: 11/14/2022] [Revised: 05/04/2023] [Accepted: 09/27/2023] [Indexed: 10/14/2023]
Abstract
OBJECTIVE Inappropriate diagnosis and treatment of asymptomatic bacteriuria (ASB) and urinary tract infection (UTI) are leading causes of antibiotic overuse but have not been well-studied in patients with risks for complicated UTI such as neurogenic bladder (NB). Our aim was to describe ASB and UTI management in patients with NB and assess factors associated with inappropriate management. DESIGN Retrospective cohort study. SETTING Four Department of Veteran's Affairs (VA) medical centers. PARTICIPANTS Adults with NB due to spinal cord injury/disorder (SCI/D), multiple sclerosis (MS), or Parkinson disease (PD) and encounters with an ASB or UTI diagnosis between 2017 and 2018. Clinical and encounter data were extracted from the VA Corporate Data Warehouse and medical record reviews for a stratified sample of 300 encounters from N=291 patients. INTERVENTIONS None. MAIN OUTCOME MEASURES Prevalence of appropriate and inappropriate ASB and UTI diagnosis and treatment was summarized. Multivariable logistic regression models assessed factors associated with inappropriate management. RESULTS N=200 UTI and N=100 ASB encounters were included for the 291 unique patients (SCI/D, 39.9%; MS, 36.4%; PD, 23.7%). Most patients were men (83.3%), >65 years (62%), and used indwelling or intermittent catheterization (68.3%). Nearly all ASB encounters had appropriate diagnosis (98%). 70 (35%) UTI encounters had inappropriate diagnosis, including 55 (27.5%) with true ASB, all with inappropriate treatment. Among the remaining 145 UTI encounters, 54 (27%) had inappropriate treatment. Peripheral vascular disease, chronic kidney disease, and cerebrovascular disease were associated with increased odds of inappropriate management; indwelling catheter (aOR 0.35, P=.01) and Physical Medicine & Rehabilitation provider (aOR 0.29, P<.01) were associated with decreased odds. CONCLUSION Up to half of UTI encounters for patients with NB had inappropriate management, largely due to inappropriate UTI diagnosis in patients with true ASB. Interventions to improve ASB and UTI management in patients with NB should target complex patients with comorbidities being seen by non-rehabilitation providers.
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Affiliation(s)
- Margaret A Fitzpatrick
- Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr VA Hospital, Hines, IL; Loyola University Chicago Stritch School of Medicine, Maywood, IL.
| | - Marissa Wirth
- Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr VA Hospital, Hines, IL
| | - Stephen P Burns
- Spinal Cord Injury/Disorders Service, VA Puget Sound Healthcare System, Seattle, WA; Department of Physical Medicine and Rehabilitation, University of Washington School of Medicine, Seattle, WA
| | - Katie J Suda
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA; Department of Medicine, Center for Research on Healthcare, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Frances M Weaver
- Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr VA Hospital, Hines, IL; Loyola University Chicago Parkinson School of Health Sciences and Public Health, Maywood, IL
| | - Eileen Collins
- College of Nursing, University of Illinois Chicago, Chicago, IL
| | - Nasia Safdar
- Department of Medicine, Division of Infectious Diseases, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI; William S. Middleton VA Hospital, Madison, WI
| | - Charlesnika T Evans
- Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr VA Hospital, Hines, IL; Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, IL
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Senthinathan A, Penner M, Tu K, Morris AM, Craven BC, Li Z, Guan J, Jaglal SB. Identifying Patterns of Primary Care Antibiotic Prescribing for a Spinal Cord Injury (SCI) Cohort Using an Electronic Medical Records (EMR) Database. Top Spinal Cord Inj Rehabil 2023; 29:153-164. [PMID: 38174137 PMCID: PMC10759849 DOI: 10.46292/sci23-00047s] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Background Individuals with a spinal cord injury (SCI) are considered higher users of antibiotics. However, to date there have been no detailed studies investigating outpatient antibiotic use in this population. Objectives (1) To describe primary care antibiotic prescribing patterns in adults with SCI rostered to a primary care physician (PCP), and (2) to identify patient or PCP factors associated with number of antibiotics prescribed and antibiotic prescription duration. Methods A retrospective cohort study using linked health administrative and electronic medical records (EMR) databases from January 1, 2013 to December 31, 2015 among 432 adults with SCI in Ontario, Canada. Negative binomial regression analyses were conducted to identify patient or physician factors associated with number of antibiotics prescribed and prescription duration. Results During the study period, 61.1% of the SCI cohort received an antibiotic prescription from their PCP. There were 59.8% of prescriptions for urinary tract infections (UTI) and 24.6% of prescriptions for fluoroquinolones. Regression analysis found catheter use was associated with increased number of antibiotics prescribed (relative risk [RR] = 3.1; 95% CI, 2.3-4.1; p < .001) and late career PCPs, compared to early-career PCPs, prescribed a significantly longer duration (RR = 1.8; 95% CI, 1.1-3.1; p = .02). Conclusion UTIs were the number one prescription indication, and fluoroquinolones were the most prescribed antibiotic. Catheter use was associated with number of antibiotics, and PCP's years of practice was associated with duration. The study provided important information about primary care antibiotic prescribing in the SCI population and found that not all individuals received frequent antibiotics prescriptions.
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Affiliation(s)
- Arrani Senthinathan
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
- KITE (Knowledge Innovation Talent Everywhere), Toronto Rehabilitation Institute - University Health Network, Toronto, ON, Canada
| | - Melanie Penner
- Bloorview Research Institute / Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON, Canada
- Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Karen Tu
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- North York General Hospital, Toronto, ON, Canada
- Toronto Western Family Health Team, University Health Network, Toronto, ON, Canada
| | - Andrew M. Morris
- Antimicrobial Stewardship Program, University Health Network, Toronto, ON, Canada
- Department of Medicine, Division of Infectious Diseases, Sinai Health, University Health Network, and University of Toronto, Toronto, ON, Canada
| | - B. Catharine Craven
- KITE (Knowledge Innovation Talent Everywhere), Toronto Rehabilitation Institute - University Health Network, Toronto, ON, Canada
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Spinal Cord Rehabilitation Program, Toronto Rehabilitation Institute – University Health Network, Toronto, ON, Canada
| | | | | | - Susan B. Jaglal
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Rehabilitation Science Institute and Department of Physical Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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Clinical outcomes associated with guideline-discordant management of asymptomatic bacteriuria and urinary tract infection in hospitalized patients with neurogenic bladder. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e195. [PMID: 36712473 PMCID: PMC9879921 DOI: 10.1017/ash.2022.348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 11/04/2022] [Accepted: 11/05/2022] [Indexed: 12/13/2022]
Abstract
Objective To compare clinical outcomes associated with appropriate and inappropriate management of asymptomatic bacteriuria (ASB) and urinary tract infection (UTI) among inpatients with neurogenic bladder (NB). Design Multicenter, retrospective cohort. Setting The study was conducted across 4 Veterans' Affairs hospitals. Participants The study included veterans with NB due to spinal cord injury or disorder (SCI/D), multiple sclerosis (MS), or Parkinson's disease (PD) hospitalized between January 1, 2017, and December 31, 2018, with diagnosis of ASB or UTI. Interventions In a medical record review, we classified ASB and UTI diagnoses and treatments as appropriate or inappropriate based on national guidelines. Main outcome measures Frequencies of Clostridioides difficile infection, acute kidney injury, 90-day hospital readmission, postculture length-of-stay (LOS), and multidrug-resistant organisms in subsequent urine cultures were compared between those who received appropriate and inappropriate management. Results We included 170 encounters with ASB (30%) or UTI (70%) diagnoses occurring for 166 patients. Overall, 86.1% patients were male, 47.6% had SCI/D and 77.6% used bladder catheters. All ASB encounters had appropriate diagnoses, and 96.1% had appropriate treatment. In contrast, 37 UTI encounters (31.1%) had inappropriate diagnoses and 61 (51.3%) had inappropriate treatment, including 30 encounters with true ASB. Among patients with SCI/D or MS, appropriate ASB or UTI diagnosis was associated with a longer postculture LOS (median, 14 vs 7.5 days; P = .02). We did not detect any significant associations between appropriate versus inappropriate diagnosis and treatment and other outcomes. Conclusions Almost one-third of UTI diagnoses and half of treatments in hospitalized patients with NB are inappropriate. Opportunities exist to improve ASB and UTI management in patients with NB to minimize inappropriate antibiotic use.
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Vivo A, Fitzpatrick MA, Suda KJ, Jones MM, Perencevich EN, Rubin MA, Ramanathan S, Wilson GM, Evans ME, Evans CT. Epidemiology and outcomes associated with carbapenem-resistant Acinetobacter baumannii and carbapenem-resistant Pseudomonas aeruginosa: a retrospective cohort study. BMC Infect Dis 2022; 22:491. [PMID: 35610601 PMCID: PMC9128216 DOI: 10.1186/s12879-022-07436-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 04/19/2022] [Indexed: 11/21/2022] Open
Abstract
Background Carbapenem-resistant Acinetobacter baumannii (CRAB) and carbapenem-resistant Pseudomonas aeruginosa (CRPA) are a growing threat. The objective of this study was to describe CRAB and CRPA epidemiology and identify factors associated with mortality and length of stay (LOS) post-culture. Methods This was a national retrospective cohort study of Veterans with CRAB or CRPA positive cultures from 2013 to 2018, conducted at Hines Veterans Affairs Hospital. Carbapenem resistance was defined as non-susceptibility to imipenem, meropenem and/or doripenem. Multivariable cluster adjusted regression models were fit to assess the association of post-culture LOS among inpatient and long-term care (LTC) and to identify factors associated with 90-day and 365-day mortality after positive CRAB and CRPA cultures. Results CRAB and CRPA were identified in 1,048 and 8,204 unique patients respectively, with 90-day mortality rates of 30.3% and 24.5% and inpatient post-LOS of 26 and 27 days. Positive blood cultures were associated with an increased odds of 90-day mortality compared to urine cultures in patients with CRAB (OR 6.98, 95% CI 3.55–13.73) and CRPA (OR 2.82, 95% CI 2.04–3.90). In patients with CRAB and CRPA blood cultures, higher Charlson score was associated with increased odds of 90-day mortality. In CRAB and CRPA, among patients from inpatient care settings, blood cultures were associated with a decreased LOS compared to urine cultures. Conclusions Positive blood cultures and more comorbidities were associated with higher odds for mortality in patients with CRAB and CRPA. Recognizing these factors would encourage clinicians to treat these patients in a timely manner to improve outcomes of patients infected with these organisms. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-022-07436-w.
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Affiliation(s)
- Amanda Vivo
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines Jr. VA Medical Center, Hines, IL, USA. .,Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines Jr. VA Medical Center, 5000 S. 5th Avenue (151H), Building 1, Room D322, Hines, IL, 60141, USA.
| | - Margaret A Fitzpatrick
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines Jr. VA Medical Center, Hines, IL, USA.,Department of Medicine, Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Katie J Suda
- Center for Health Equity Research and Promotion, VA Pittsburgh Health Care System, Pittsburgh, PA, USA.,School of Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Makoto M Jones
- Department of Veterans' Affairs, VA Salt Lake City Healthcare System, Salt Lake City, UT, USA.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Eli N Perencevich
- Department of Veterans' Affairs, Iowa City VA Health Care System, Iowa City, IA, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Michael A Rubin
- Department of Veterans' Affairs, VA Salt Lake City Healthcare System, Salt Lake City, UT, USA.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Swetha Ramanathan
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines Jr. VA Medical Center, Hines, IL, USA
| | - Geneva M Wilson
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines Jr. VA Medical Center, Hines, IL, USA.,Department of Preventive Medicine, Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Martin E Evans
- MRSA/MDRO Program, VHA National Infectious Diseases Service, VA Central Office and the Lexington VA Medical Center, Lexington, KY, USA.,Department of Internal Medicine, University of Kentucky School of Medicine, Lexington, KY, USA
| | - Charlesnika T Evans
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines Jr. VA Medical Center, Hines, IL, USA.,Preventive Medicine and Center for Health Services and Outcomes Research, Northwestern University, Chicago, IL, USA
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Sanchez BC, Heckmann ER, Green SI, Clark JR, Kaplan HB, Ramig RF, Muldrew KL, Hines-Munson C, Skelton F, Trautner BW, Maresso AW. Development of Phage Cocktails to Treat E. coli Catheter-Associated Urinary Tract Infection and Associated Biofilms. Front Microbiol 2022; 13:796132. [PMID: 35620093 PMCID: PMC9127763 DOI: 10.3389/fmicb.2022.796132] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 04/04/2022] [Indexed: 11/16/2022] Open
Abstract
High rates of antimicrobial resistance and formation of biofilms makes treatment of Escherichia coli catheter-associated urinary tract infections (CAUTI) particularly challenging. CAUTI affect 1 million patients per year in the United States and are associated with morbidity and mortality, particularly as an etiology for sepsis. Phage have been proposed as a potential therapeutic option. Here, we report the development of phage cocktails that lyse contemporary E. coli strains isolated from the urine of patients with spinal cord injury (SCI) and display strong biofilm-forming properties. We characterized E. coli phage against biofilms in two in vitro CAUTI models. Biofilm viability was measured by an MTT assay that determines cell metabolic activity and by quantification of colony forming units. Nine phage decreased cell viability by >80% when added individually to biofilms of two E. coli strains in human urine. A phage cocktail comprising six phage lyses 82% of the strains in our E. coli library and is highly effective against young and old biofilms and against biofilms on silicon catheter materials. Using antibiotics together with our phage cocktail prevented or decreased emergence of E. coli resistant to phage in human urine. We created an anti-biofilm phage cocktail with broad host range against E. coli strains isolated from urine. These phage cocktails may have therapeutic potential against CAUTI.
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Affiliation(s)
- Belkys C. Sanchez
- Tailored Antibacterials and Innovative Laboratories for Phage (Φ) Research, Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, United States
| | - Emmaline R. Heckmann
- Tailored Antibacterials and Innovative Laboratories for Phage (Φ) Research, Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, United States
| | - Sabrina I. Green
- Tailored Antibacterials and Innovative Laboratories for Phage (Φ) Research, Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, United States
| | - Justin R. Clark
- Tailored Antibacterials and Innovative Laboratories for Phage (Φ) Research, Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, United States
| | - Heidi B. Kaplan
- Department of Microbiology and Molecular Genetics, McGovern Medical School, UTHealth Houston, Houston, TX, United States
| | - Robert F. Ramig
- Tailored Antibacterials and Innovative Laboratories for Phage (Φ) Research, Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, United States
| | - Kenneth L. Muldrew
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, United States,Pathology and Laboratory Medicine, Michael E. DeBakey VA Medical Center, Houston, TX, United States,Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Casey Hines-Munson
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, United States
| | - Felicia Skelton
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, United States,H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, United States
| | - Barbara W. Trautner
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, United States,Department of Medicine and Surgery, Baylor College of Medicine, Houston, TX, United States,Center for Translational Research on Inflammatory Diseases, Michael E. DeBakey VA Medical Center, Houston, TX, United States
| | - Anthony W. Maresso
- Tailored Antibacterials and Innovative Laboratories for Phage (Φ) Research, Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, United States,*Correspondence: Anthony W. Maresso,
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Šámal V, Paldus V, Fáčková D, Mečl J, Šrám J. The prevalence of antibiotic-resistant and multidrug-resistant bacteria in urine cultures from inpatients with spinal cord injuries and disorders: an 8-year, single-center study. BMC Infect Dis 2022; 22:239. [PMID: 35264096 PMCID: PMC8908566 DOI: 10.1186/s12879-022-07235-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 03/02/2022] [Indexed: 11/13/2022] Open
Abstract
Background Patients, especially inpatients, with spinal cord lesions and disorders (SCI/D) have an elevated risk of recurrent urinary tract infections with multidrug resistant (MDR) bacteria. This study evaluated antimicrobial resistance and the prevalence of multidrug resistance and determined the risk factors for multidrug resistance. Methods In this retrospective cohort study, urine culture results were used to calculate the antimicrobial resistance rate and the incidence of infection with MDR bacteria in the SCI/D population. MDR was defined as acquired nonsusceptibility to at least one agent from three or more antimicrobial categories. The cohort included 402 inpatients from 2013 to 2020, with 1385 urine isolates. We included only the first isolate; duplicate isolates, defined as positive cultures of the same strain within 14 days, were excluded from the evaluation. Results The most common MDR strains were Klebsiella spp. (29%) and Escherichia coli (24%). MDR isolates were detected in 50% of the samples and extended spectrum beta-lactamase (ESBL)-producing isolates were detected in 26%, while carbapenem resistance was found in 0.1%. Significantly higher rates of infection with MDR bacteria were identified in groups of patients with indwelling urethral/suprapubic catheters (p = 0.003) and severity scores of C1–C4/AIS A–C (p = 0.01). We identified age (OR: 0.99, 95% CI; 0.98–0.99, p = 0.000), sex (OR: 1.55, 95% CI; 1.16–2.06, p = 0.003), management with urethral/suprapubic catheters (OR: 2.76, 95% CI; 2.04–3.74, p = 0.000), and spontaneous voiding (OR: 1.84, 95% CI; 1.03–3.29, p = 0.038) as independent predictors of multidrug resistance in our study population. Conclusions We identified a high antibiotic resistance rate and an increasing prevalence of infection with MDR bacteria in the SCI/D inpatient population. Particular attention should be given to bladder management, with an emphasis on minimizing the use of indwelling catheters.
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Affiliation(s)
- Vladimír Šámal
- Department of Urology, Krajská Nemocnice Liberec, Husova 10, 46063, Liberec, Czech Republic.
| | - Vít Paldus
- Department of Urology, Krajská Nemocnice Liberec, Husova 10, 46063, Liberec, Czech Republic
| | - Daniela Fáčková
- Department of Microbiology, Krajská Nemocnice Liberec, Liberec, Czech Republic
| | - Jan Mečl
- Department of Urology, Krajská Nemocnice Liberec, Husova 10, 46063, Liberec, Czech Republic
| | - Jaroslav Šrám
- Traumatology and Orthopedics Center, Krajská Nemocnice Liberec, Liberec, Czech Republic
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Multidrug-resistant bacteria in urine culture among patients with spinal cord injury and disorder: Time to first detection and analysis of risk factors. Spinal Cord 2022; 60:733-738. [PMID: 35197573 DOI: 10.1038/s41393-022-00774-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 02/06/2022] [Accepted: 02/08/2022] [Indexed: 11/08/2022]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES The aim of this study was to assess the time to first detection of multidrug-resistant bacteria (MDRB) in urine culture and identify risk factors associated with the first detection of MDRB (1st MDRB). SETTING Spinal Care Ward and Department of Microbiology, Regional Hospital Liberec a.s., Liberec, Czech Republic. METHOD We cultured urine samples from patients in the acute phase of spinal cord injury or disorder (SCI/D). Multidrug resistance (MDR) was defined as acquired nonsusceptibility to at least one agent from three or more antimicrobial categories. Multivariate logistic regression was used to assess the association of bladder management, broad-spectrum antibiotic exposure, mechanical ventilation, pressure ulcers, positive urine culture on admission, and other risk factors with 1st MDRB. We used only the first urine culture with MDRB for evaluation. RESULTS A total of 655 urine cultures from 246 individuals were evaluated, and 829 isolates were obtained. The MDRB prevalence among all isolates was 40.2%. MDRB was detected in 146 (59.3%) patients for the first time, and 76.0% of these isolates were from patients with asymptomatic bacteriuria. The median time to 1st MDRB was 37 days (95% CI, 33-41). According to multivariate logistic regression, 1st MDRB was associated with bladder management with urethral or suprapubic catheterization (OR: 2.8, 95% CI, 1.1-7.2). CONCLUSION The prevalence of infections caused by MDRB was high among the SCI/D population, with three-quarters from patients with asymptomatic bacteriuria. Bladder management with an indwelling catheter is associated with an increased risk of 1st MDRB.
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Kim E, Lee HJ, Kim O, Park IS, Lee BS. Should We Delay Urodynamic Study When Patients With Spinal Cord Injury Have Asymptomatic Pyuria? Ann Rehabil Med 2021; 45:178-185. [PMID: 34126670 PMCID: PMC8273722 DOI: 10.5535/arm.20241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 02/09/2021] [Indexed: 11/05/2022] Open
Abstract
Objective To assess the incidence of urinary tract infection (UTI) with post-urodynamic study (post-UDS) in patients with spinal cord injury (SCI) and study its relationship with pre-UDS pyuria. Methods Patients with SCI who were hospitalized and underwent UDS during a 4-year period were reviewed. Patients with pre-test lower urinary tract symptoms were excluded. Urinalysis and urine culture were performed before and 24 hours after UDS. Prophylactic antibiotics were administered for 5 days starting from the morning of the UDS. UTI was defined as bacteriuria with accompanying symptoms. Results Of 399 patients reviewed, 209 (52.4%) had pyuria in pre-UDS urinalysis, and 257 (64.4%) had bacteriuria in pre-UDS culture. Post-UDS UTI occurred in 6 (1.5%) individuals who all complained of fever: 5 (2.4%) of the post-UDS UTI cases occurred in patients with pre-UDS pyuria, and 1 (0.5%) in a person without. The differences between groups were not statistically significant (p=0.218). Of 221 patients with bacteriuria (gram-negative isolates) on pre-UDS culture, resistance to ciprofloxacin, cephalosporin, and trimethoprim/sulfamethoxazole (TMP/SMT) was noted in 52.9% (117 cases), 57.0% (126 cases), and 38.9% (86 cases), respectively. Conclusion No difference was found in the prevalence of post-UDS UTI based on the presence of pyuria in pre-UDS urinalysis. UDS may be performed even in SCI cases of pre-UDS pyuria without increasing the prevalence of post-UDS UTI if prophylactic antibiotics are administered. TMP/SMT could be used as a first-line antibiotic for the prevention of post-UDS UTI in Korea.
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Affiliation(s)
- EunYoung Kim
- Department of Physical Medicine and Rehabilitation, National Rehabilitation Center, Seoul, Korea
| | - Hye Jin Lee
- Department of Physical Medicine and Rehabilitation, National Rehabilitation Center, Seoul, Korea
| | - Onyoo Kim
- Department of Physical Medicine and Rehabilitation, National Rehabilitation Center, Seoul, Korea
| | - In Suk Park
- Department of Nursing, National Rehabilitation Center, Seoul, Korea
| | - Bum-Suk Lee
- Department of Physical Medicine and Rehabilitation, National Rehabilitation Center, Seoul, Korea
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11
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Milligan J, Goetz LL, Kennelly MJ. A Primary Care Provider's Guide to Management of Neurogenic Lower Urinary Tract Dysfunction and Urinary Tract Infection After Spinal Cord Injury. Top Spinal Cord Inj Rehabil 2020; 26:108-115. [PMID: 32760189 DOI: 10.46292/sci2602-108] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Neurogenic lower urinary tract dysfunction (NLUTD), previously termed neurogenic bladder dysfunction, is a common secondary complication of spinal cord injury (SCI). It is associated with significant morbidity, reduced quality of life, increased health care costs, and mortality. Primary care providers (PCPs) play an important role in optimizing urohealth over the life span. This article will review NLUTD in SCI, its complication, surveillance, and management. PCPs should be aware of SCI-related NLUTD, its complications, management, and surveillance recommendations, and when to refer to a specialist.
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Affiliation(s)
- James Milligan
- The Centre for Family Medicine, Kitchener, Ontario, Canada.,McMaster University Department of Family Medicine, Hamilton, Ontario, Canada
| | - Lance L Goetz
- Department of Veterans Affairs, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia.,Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, Virginia
| | - Michael J Kennelly
- Carolinas Rehabilitation, Charlotte, North Carolina.,Atrium Health, Charlotte, North Carolina
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12
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Evans CT, Fitzpatrick M, Ramanathan S, Kralovic SM, Burns SP, Goldstein B, Smith B, Gerding DN, Johnson S. Healthcare facility-onset, healthcare facility-associated Clostridioides difficile infection in Veterans with spinal cord injury and disorder. J Spinal Cord Med 2020; 43:642-652. [PMID: 31663843 PMCID: PMC7534364 DOI: 10.1080/10790268.2019.1672953] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Objective: To describe the burden and risk of healthcare facility-onset, healthcare facility-associated (HO-HCFA) Clostridioides difficile infection (CDI) in Veterans with spinal cord injury and disorder (SCI/D). Design: Retrospective, longitudinal cohort study from October 1, 2001-September 30, 2010. Setting: Ninety-four acute care Veterans Affairs facilities. Participants: Patients with SCI/D. Outcomes: Incidence rate of HO-HCFA CDI. Methods: Rates of CDI were determined, and crude unadjusted incidence rate ratios (IRRs) and 95% confidence intervals (CIs) were calculated. Multivariable Poisson random-effects regression analyses were used to assess factors independently associated with the rate of CDI. Results: 1,409 cases of HO-HCFA CDI were identified. CDI rates in 2002 were 13.9/10,000 person-days and decreased to 5.5/10,000 person-days by 2010. Multivariable regression analyses found that antibiotic (IRR = 18.79, 95% CI 14.09-25.07) and proton-pump inhibitor (PPI) or H2 blocker use (IRR = 7.71, 95% CI 5.47-10.86) were both independently associated with HO-HCFA CDI. Exposure to both medications demonstrated a synergistic risk (IRR = 37.55, 95% CI 28.39-49.67). Older age, Northeast region, and invasive respiratory procedure in the prior 30 days were also independent risk factors, while longer SCI duration and care at a SCI center were protective. Conclusion: Although decreasing, CDI rates in patients with SCI/D remain high. Targeted antimicrobial stewardship and pharmacy interventions that reduce antibiotic and PPI/H2 blocker use could have profound benefits in decreasing HO-HCFA CDI in this high-risk population.
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Affiliation(s)
- Charlesnika T. Evans
- Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr VA Hospital, Hines, Illinois, USA
- Department of Preventive Medicine and Center for Healthcare Studies, Northwestern University, Chicago, Illinois, USA
| | - Margaret Fitzpatrick
- Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr VA Hospital, Hines, Illinois, USA
- Department of Medicine, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois, USA
| | - Swetha Ramanathan
- Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr VA Hospital, Hines, Illinois, USA
| | - Stephen M. Kralovic
- Cincinnati VA Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Stephen P. Burns
- VA Puget Sound Health Care System, Seattle, Washington, USA
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | | | - Bridget Smith
- Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr VA Hospital, Hines, Illinois, USA
- Department of Pediatrics and Center for Community Health, Northwestern University, Chicago, Illinois, USA
| | - Dale N. Gerding
- Department of Veterans Affairs, Research Service, Edward Hines Jr VA Hospital, Hines, Illinois, USA
| | - Stuart Johnson
- Department of Medicine, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois, USA
- Department of Veterans Affairs, Research Service, Edward Hines Jr VA Hospital, Hines, Illinois, USA
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13
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Improving Antimicrobial Use in Adult Outpatient Clinics: the New Frontier for Antimicrobial Stewardship Programs. Curr Infect Dis Rep 2020. [DOI: 10.1007/s11908-020-00722-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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14
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Toh SL, Lee BB, Simpson JM, Rice SA, Kotsiou G, Marial O, Ryan S. Effect of probiotics on multi-resistant organism colonisation in persons with spinal cord injury: secondary outcome of ProSCIUTTU, a randomised placebo-controlled trial. Spinal Cord 2020; 58:755-767. [PMID: 31953482 DOI: 10.1038/s41393-020-0420-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 01/03/2020] [Accepted: 01/09/2020] [Indexed: 12/25/2022]
Abstract
STUDY DESIGN Randomised double-blind placebo-controlled trial. OBJECTIVES Multi-resistant organism (MRO) colonisation is common in people with SCI. We aimed to determine whether Lactobacillus reuteri RC-14 + Lactobacillus GR-1 (RC14-GR1) and/or Lactobacillus rhamnosus GG + Bifidobacterium BB-12 (LGG-BB12) are effective in preventing or clearing MRO colonisation. SETTING New South Wales, Australia. METHODS The 207 SCI participants were randomised to one of four arms: (i) RC14-GR1 + LGG-BB12, (ii) RC14-GR1 + placebo, (iii) LGG-BB12 + placebo or (iv) double placebos for 6 months. Microbiological samples of nose, groin, urine and bowel were taken at baseline, 3 and 6 months. Analysis was conducted for the presence of methicillin-resistant Staphylococcus aureus (MRSA), multi-resistant gram-negative organisms (MRGNs) and vancomycin-resistant enterococcus (VRE). The outcomes were clearance of, or new colonisation with MRSA, MRGN, VRE or MROs and whether participants remained free of MRSA, MRGN, VRE or MROs throughout the study. Risk factors associated with an outcome were adjusted for using nominal or binary logistic regression. RESULTS There was a significant reduction in new MRGN colonisation compared with placebo for participants treated with RC14-GR1 (OR 0.10, 95% CI, 0.01-0.88, P = 0.04), after allowing that inpatients were more likely to be newly colonised (OR 21.41, 95% CI, 3.98-115.13, P < 0.0001). Participants who intermittent self-catheterised (IMC) were more likely to remain MRO-free than those utilising SPC or IDCs (OR 2.80, 95% CI, 1.41-5.54, P = 0.009). CONCLUSIONS Probiotics are ineffective at clearing MROs in people with SCI. However, RC14-GR1 is effective at preventing new colonisation with MRGNs. The use of IMC significantly improves the chance of remaining MRO-free.
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Affiliation(s)
- Swee-Ling Toh
- Department of Spinal and Rehabilitation Medicine, Prince of Wales Hospital, Sydney, NSW, Australia. .,Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia.
| | - Bonsan Bonne Lee
- Department of Spinal and Rehabilitation Medicine, Prince of Wales Hospital, Sydney, NSW, Australia.,Neuroscience Research Australia (NeuRA) and UNSW Sydney, Sydney, NSW, Australia
| | - Judy M Simpson
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Scott A Rice
- Singapore Centre for Environmental Life Sciences Engineering and the School of Biological Sciences, Nanyang Technological University, Nanyang, Singapore.,The ithree Institute, University of Technology Sydney, Sydney, NSW, Australia
| | - George Kotsiou
- Department of Infectious Diseases and Microbiology, NSW Health Pathology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Obaydullah Marial
- Neuroscience Research Australia (NeuRA) and UNSW Sydney, Sydney, NSW, Australia
| | - Suzanne Ryan
- Neuroscience Research Australia (NeuRA) and UNSW Sydney, Sydney, NSW, Australia
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15
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Chew AB, Suda KJ, Patel UC, Fitzpatrick MA, Ramanathan S, Burns SP, Evans CT. Long-term prescribing of nitrofurantoin for urinary tract infections (UTI) in veterans with spinal cord injury (SCI). J Spinal Cord Med 2019; 42:485-493. [PMID: 29985783 PMCID: PMC6718139 DOI: 10.1080/10790268.2018.1488096] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
CONTEXT/OBJECTIVE To evaluate the impact of long-term nitrofurantoin for UTI prophylaxis in veterans with SCI. DESIGN Matched pairs study. SETTING Veterans cared for at VA facilities from 10/1/2012-9/30/2013. PARTICIPANTS Veterans. INTERVENTIONS n/a. OUTCOMES MEASURES UTI, positive urine cultures, resistant cultures. METHODS Cases receiving long-term nitrofurantoin (≥90 days supply) were matched to controls by facility. Controls were patients who did not receive long-term nitrofurantoin with a history of ≥3 positive urine cultures and at least one diagnosis of UTI or asymptomatic bacteriuria in the previous year. RESULTS 122 SCI cases were identified and matched to 196 controls. After adjusting for differences in baseline demographic characteristics, UTIs were less frequent in cases (OR = 0.60 [95% CI 0.44-0.72]). Cases had a greater mean number of days between positive urine cultures as compared to controls (<0.0001). Cases were more likely to have isolates resistant to nitrofurantoin (P ≤ 0.0001); however, the frequency of multi-drug resistant organisms isolated from the urine was not significantly different. CONCLUSIONS Long-term prescription of nitrofurantoin may reduce UTIs in veterans with SCI and there is no evidence that it promotes multi-drug resistance. Future prospective studies should be conducted prior to incorporating routine use of long-term nitrofurantoin into clinical care.
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Affiliation(s)
- Alexander B. Chew
- Pharmacy Service, Edward Hines, Jr. Veterans Affairs Hospital, Hines, Illinois, USA
| | - Katie J. Suda
- Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. Veterans Affairs Hospital, Hines, Illinois, USA
- Department of Pharmacy Systems, Outcomes, and Policy, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Ursula C. Patel
- Pharmacy Service, Edward Hines, Jr. Veterans Affairs Hospital, Hines, Illinois, USA
| | - Margaret A. Fitzpatrick
- Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. Veterans Affairs Hospital, Hines, Illinois, USA
- Department of Medicine, Loyola University Stritch School of Medicine, Maywood, Illinois, USA
| | - Swetha Ramanathan
- Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. Veterans Affairs Hospital, Hines, Illinois, USA
| | - Stephen P. Burns
- Spinal Cord Injury Service, VA Puget Sound Health Care Service, Seattle, Washington, USA
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Charlesnika T. Evans
- Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. Veterans Affairs Hospital, Hines, Illinois, USA
- Department of Preventive Medicine and Center for Healthcare Studies, Northwestern University, Chicago, Illinois, USA
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16
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Lepainteur M, Ogna A, Clair B, Dinh A, Tarragon C, Prigent H, Davido B, Barbot F, Vaugier I, Afif M, Roux AL, Rottman M, Orlikowski D, Herrmann JL, Annane D, Lawrence C. Risk factors for respiratory tract bacterial colonization in adults with neuromuscular or neurological disorders and chronic tracheostomy. Respir Med 2019; 152:32-36. [PMID: 31128607 DOI: 10.1016/j.rmed.2019.04.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 04/16/2019] [Accepted: 04/17/2019] [Indexed: 11/30/2022]
Abstract
The aim of this study was to describe the endotracheal respiratory flora in a population of adults suffering from neuromuscular or neurological disorders requiring a long-term tracheostomy and to identify risk factors for colonization. We conducted a prospective and single-center observational study among patients with chronic tracheostomy admitted for planned respiratory assessment between February 2015 and December 2016. Data were collected from patient interview and medical charts with a standardized questionnaire. A tracheal aspiration was performed for each patient. Humidifiers were analysed for bacteriological contamination. Overall 77 tracheal aspirates (TA) were obtained from patients included. Pathogenic bacteria were found in 90% of cases (69/77) with a majority of Pseudomonas aeruginosa (32/77, 41%), Staphylococcus aureus (34/77, 44%) and Serratia marcesens. (22/79, 38%) Amoxicillin + Clavulanic-acid and Cefotaxime were adapted for respectively in only 28% and 35% of the subjects due to the natural resistance of organisms. No pathogenic bacteria were isolated from humidifier samples. Risk factors significantly associated with P. aeruginosa colonization were residence in a medical-care home (p = 0.01, OR = 3.8 [1.1; 15.1]) and the presence of a cuff (p = 0.003, OR = 4.4 [1.1; 20.6]). Significant quantities of pathogenic bacteria are frequently isolated from TA of tracheostomised patients in the absence of infection. The frequent resistance of these pathogens to Amoxicillin + Clavulanic-acid precludes the use of this antibiotic in the empiric treatment of pneumonia in this population.
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Affiliation(s)
- Margaux Lepainteur
- Laboratoire de microbiologie et unité d'hygiène hospitalière APHP, Hôpitaux Universitaires Paris Ile de France Ouest, site R. Poincaré, 92380, Garches, France
| | - Adam Ogna
- Réanimation adultes, APHP, Hôpitaux Universitaires Paris Ile de France Ouest, site R. Poincaré, 92380, Garches, France
| | - Bernard Clair
- Réanimation adultes, APHP, Hôpitaux Universitaires Paris Ile de France Ouest, site R. Poincaré, 92380, Garches, France
| | - Aurélien Dinh
- Maladies infectieuses, APHP, Hôpitaux Universitaires Paris Ile de France Ouest, site R. Poincaré, 92380, Garches, France
| | - Catherine Tarragon
- Réanimation adultes, APHP, Hôpitaux Universitaires Paris Ile de France Ouest, site R. Poincaré, 92380, Garches, France
| | - Hélène Prigent
- Réanimation adultes, APHP, Hôpitaux Universitaires Paris Ile de France Ouest, site R. Poincaré, 92380, Garches, France
| | - Benjamin Davido
- Maladies infectieuses, APHP, Hôpitaux Universitaires Paris Ile de France Ouest, site R. Poincaré, 92380, Garches, France
| | - Frédéric Barbot
- CIC1429 INSERM AP-HP, Hôpitaux Universitaires Paris Ile de France Ouest, site R. Poincaré, 92380, Garches, France
| | - Isabelle Vaugier
- CIC1429 INSERM AP-HP, Hôpitaux Universitaires Paris Ile de France Ouest, site R. Poincaré, 92380, Garches, France
| | - Muriel Afif
- Pharmacie hospitalière, APHP, Hôpitaux Universitaires Paris Ile de France Ouest, site R. Poincaré, 92380, Garches, France
| | - Anne-Laure Roux
- Laboratoire de microbiologie et unité d'hygiène hospitalière APHP, Hôpitaux Universitaires Paris Ile de France Ouest, site R. Poincaré, 92380, Garches, France; INSERM U1173, UFR Simone Veil, Versailles-Saint-Quentin University, 78180, Saint-Quentin en Yvelines, France
| | - Martin Rottman
- Laboratoire de microbiologie et unité d'hygiène hospitalière APHP, Hôpitaux Universitaires Paris Ile de France Ouest, site R. Poincaré, 92380, Garches, France; INSERM U1173, UFR Simone Veil, Versailles-Saint-Quentin University, 78180, Saint-Quentin en Yvelines, France
| | - David Orlikowski
- Réanimation adultes, APHP, Hôpitaux Universitaires Paris Ile de France Ouest, site R. Poincaré, 92380, Garches, France; CIC1429 INSERM AP-HP, Hôpitaux Universitaires Paris Ile de France Ouest, site R. Poincaré, 92380, Garches, France
| | - Jean-Louis Herrmann
- Laboratoire de microbiologie et unité d'hygiène hospitalière APHP, Hôpitaux Universitaires Paris Ile de France Ouest, site R. Poincaré, 92380, Garches, France; INSERM U1173, UFR Simone Veil, Versailles-Saint-Quentin University, 78180, Saint-Quentin en Yvelines, France
| | - Djillali Annane
- Réanimation adultes, APHP, Hôpitaux Universitaires Paris Ile de France Ouest, site R. Poincaré, 92380, Garches, France
| | - Christine Lawrence
- Laboratoire de microbiologie et unité d'hygiène hospitalière APHP, Hôpitaux Universitaires Paris Ile de France Ouest, site R. Poincaré, 92380, Garches, France; INSERM U1173, UFR Simone Veil, Versailles-Saint-Quentin University, 78180, Saint-Quentin en Yvelines, France.
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17
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Fitzpatrick MA, Suda KJ, Burns SP, Poggensee L, Ramanathan S, Evans CT. Pre-operative screening for asymptomatic bacteriuria and associations with post-operative outcomes in patients with spinal cord injury. J Spinal Cord Med 2019; 42:255-259. [PMID: 29578382 PMCID: PMC6421984 DOI: 10.1080/10790268.2018.1451237] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
CONTEXT Screening for asymptomatic bacteriuria (ASB) before non-urologic surgery is common but of unclear benefit. Our aim was to describe pre-operative ASB screening and post-operative outcomes in patients with neurogenic bladder due to spinal cord injury (SCI). METHODS This was a descriptive retrospective cohort study of adults with SCI undergoing neurosurgical spine or orthopedic lower limb surgery from 10/1/2012-9/30/2014 at Veterans Affairs (VA) medical centers. National VA datasets and medical record review was used to describe frequency of pre-operative ASB screening, presence of ASB, and association with post-operative surgical site infection, urinary tract infection, and hospital readmission. RESULTS 175 patients were included. Although over half of patients had pre-operative ASB screening, only 30.8% actually had pre-operative ASB. 15.2% of patients screened were treated for ASB with antibiotics before surgery. Post-operative urinary tract infection (UTI) or surgical site infection (SSI) occurred in 10 (5.7%) patients, and 20 patients (11.4%) were readmitted within 30 days. Neither ASB screening nor the presence of pre-operative ASB were associated with these post-op outcomes (p > 0.2 for all). CONCLUSION Pre-operative ASB screening is common in patients with SCI undergoing elective spine and lower limb surgery, although ASB occurs in less than 1/3rd of cases. There were no associations between pre-operative ASB and outcomes. Further studies evaluating the clinical benefit of this practice in patients with SCI should be performed.
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Affiliation(s)
- Margaret A. Fitzpatrick
- Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, Hines, Illinois, USA,Loyola University Chicago Stritch School of Medicine, Maywood, Illinois, USA,Correspondence to: Margaret A. Fitzpatrick, Loyola University Chicago Stritch School of Medicine, 2160 S. First Ave., Building 154, Room 111, Maywood, IL50153, USA.
| | - Katie J. Suda
- Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, Hines, Illinois, USA,University of Illinois at Chicago, Chicago, Illinois, USA
| | - Stephen P. Burns
- VA Puget Sound Healthcare System, Seattle, Washington, USA,University of Washington School of Medicine, Seattle, Washington, USA
| | - Linda Poggensee
- Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, Hines, Illinois, USA
| | - Swetha Ramanathan
- Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, Hines, Illinois, USA
| | - Charlesnika T. Evans
- Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, Hines, Illinois, USA,Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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18
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Skelton F, Suda K, Evans C, Trautner B. Effective antibiotic stewardship in spinal cord injury: Challenges and a way forward. J Spinal Cord Med 2019; 42:251-254. [PMID: 29324181 PMCID: PMC6419644 DOI: 10.1080/10790268.2017.1396183] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
CONTEXT Antibiotic stewardship, defined as a multidisciplinary program to reduce the misuse of antibiotics, and in turn, antibiotic resistance, is a high priority. Persons with spinal cord injury/disorder (SCI/D) are vulnerable to receiving multiple courses of antibiotics over their lifetime given frequent healthcare exposure, and have high rates of bacterial infection with multi-drug resistant organisms. Additional challenges to evaluating appropriate use of antibiotics in this population include bacterial colonization in the urine and the differences in the presenting signs and symptoms of infection. Therefore, Veterans Health Administration (VHA) facilities with SCI/D centers need effective antibiotic stewardship programs. RESULTS We analyzed the results of a 2012 VHA-wide survey evaluating available antibiotic stewardship resources, and compared the resources present at facilities with SCI/D (n=23) versus non-SCI/D facilities (n=107). VHA facilities with SCI/D centers are more likely to have components of an antibiotic stewardship program that have led to reduced antibiotic use in previous studies. They are also more likely to have personnel with infectious diseases training. CONCLUSION VHA facilities with SCI/D centers have the resources needed for antibiotic stewardship. The next step will be to determine how to implement effective antibiotic stewardship tailored for this patient care setting.
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Affiliation(s)
- Felicia Skelton
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey VA Medical Center, Houston, Texas,Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas,Correspondence to: Felicia Skelton, MD, BS, Michael E. DeBakey VA Medical Center, Houston Center for Innovations in Quality, Effectiveness & Safety (IQuESt), 2002 Holcombe Blvd. (152), Houston, TX77030.
| | - Katie Suda
- Center for Innovation for Complex Chronic Care (CINCCH), Edward Hines Jr. VA Hospital, Hines, Illinois,University of Illinois at Chicago, Chicago, Illinois
| | - Charlesnika Evans
- Center for Innovation for Complex Chronic Care (CINCCH), Edward Hines Jr. VA Hospital, Hines, Illinois,Northwestern University, Department of Preventive Medicine and Center for Health Care Studies, Institute for Public Health and Medicine, Feinberg School of Medicine, Chicago, Illinois
| | - Barbara Trautner
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey VA Medical Center, Houston, Texas,Department of Medicine, Baylor College of Medicine, Houston, Texas
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19
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Fitzpatrick MA, Suda KJ, Jones MM, Burns SP, Poggensee L, Ramanathan S, Evans M, Evans CT. Effect of varying federal definitions on prevalence and characteristics associated with carbapenem-resistant Enterobacteriaceae in veterans with spinal cord injury. Am J Infect Control 2019; 47:175-179. [PMID: 30301655 PMCID: PMC8575162 DOI: 10.1016/j.ajic.2018.08.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 08/01/2018] [Accepted: 08/01/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Patients with spinal cord injury (SCI) have a high risk for multidrug-resistant organisms, including carbapenem-resistant Enterobacteriaceae (CRE). Accurate and easily applied definitions are critical to identify CRE. This study describes CRE and associated characteristics in veterans with SCI per Centers for Disease Control and Prevention (CDC) and Department of Veterans Affairs (VA) definitions. METHODS A retrospective cohort of veterans with SCI and more than 1 culture with Escherichia coli, Klebsiella spp and/or Enterobacter spp between 2012 and 2013 was examined. Antibiotic susceptibility criteria of pre-2015 (CDC1) and post-2015 (CDC2) CDC definitions and pre-2017 (VA1) and post-2017 (VA2) VA definitions were used to identify CRE. CRE prevalence and characteristics are described for isolates meeting each definition, and agreement was assessed with the Cohen kappa. RESULTS We reviewed 21,514 isolates cultured from 6,974 veterans; 423 isolates met any CRE definition. Although agreement among definitions was high (kappa = 0.82-0.93), definitions including ertapenem resistance led to higher CRE prevalence (VA1 = 1.7% and CDC2 = 1.9% vs VA2 = 1.4% and CDC1 = 1.5%). Forty-four of 142 VA facilities had more than 1 CRE case defined by VA2; 10 facilities accounted for 60% of CRE cases. Almost all CRE was isolated from high-complexity, urban facilities, and the South had the highest proportion of CRE. CONCLUSIONS Varying federal definitions give different CRE frequencies in a high-risk population. Definitions including ertapenem resistance resulted in higher CRE prevalence but may overemphasize noncarbapenemase isolates. Thus, both federal definitions now highlight the importance of carbapenemase testing.
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Affiliation(s)
- Margaret A Fitzpatrick
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Department of Veterans Affairs, Edward Hines Jr VA Hospital, Hines, IL; Department of Medicine, Division of Infectious Diseases, Loyola University Chicago Stritch School of Medicine, Chicago, IL.
| | - Katie J Suda
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Department of Veterans Affairs, Edward Hines Jr VA Hospital, Hines, IL; Department of Pharmacy, Systems, Outcomes, and Policy, College of Pharmacy, University of Illinois-Chicago, Chicago, IL
| | - Makoto M Jones
- Department of Veterans Affairs, VA Salt Lake City Healthcare System, Salt Lake City, UT; Department of Medicine, Division of Epidemiology, University of Utah, Salt Lake City, UT
| | - Stephen P Burns
- Spinal Cord Injury Service, Department of Veterans Affairs, VA Puget Sound Health Care System, Seattle, WA; Department of Rehabilitation Medicine, University of Washington, Seattle, WA
| | - Linda Poggensee
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Department of Veterans Affairs, Edward Hines Jr VA Hospital, Hines, IL
| | - Swetha Ramanathan
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Department of Veterans Affairs, Edward Hines Jr VA Hospital, Hines, IL
| | - Martin Evans
- Department of Veterans Affairs, Lexington VA Medical Center, Lexington, KY; MRSA/MDRO Program Office, National Infectious Diseases Service, Specialty Care Services, Veterans Health Administration, Cincinnati, OH; Department of Medicine, Division of Infectious Diseases, University of Kentucky School of Medicine, Lexington, KY
| | - Charlesnika T Evans
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Department of Veterans Affairs, Edward Hines Jr VA Hospital, Hines, IL; Department of Preventive Medicine and Center for Health Care Studies, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
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Skelton-Dudley F, Doan J, Suda K, Holmes SA, Evans C, Trautner B. Spinal Cord Injury Creates Unique Challenges in Diagnosis and Management of Catheter-Associated Urinary Tract Infection. Top Spinal Cord Inj Rehabil 2019; 25:331-339. [PMID: 31844385 PMCID: PMC6907033 DOI: 10.1310/sci2504-331] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background: Catheter-associated urinary tract infection (CAUTI) is associated with increased morbidity and mortality and influences the quality of life of patients with spinal cord injury (SCI). Objectives: This clinical review aims to highlight the unique surveillance, prevention, diagnosis, and management challenges of CAUTI in the SCI population. Methods: Narrative review of the current literature on catheter use in persons with SCI was conducted to determine gaps in knowledge and opportunities for improvement. Results: Surveillance of CAUTI is challenging in the SCI population as the ability to detect symptoms used to diagnose CAUTI (ie, suprapubic pain, dysuria) is impaired. In terms of prevention of CAUTI, current strategies refocus on appropriate catheter insertion and care and early removal of catheters, which is not always feasible for persons with SCI. Prophylactic antibiotics, nutraceuticals, and coated catheters show limited efficacy in infection prevention. Diagnosing CAUTI after SCI is challenging, often resulting in an overdiagnosis of CAUTI when truly asymptomatic bacteriuria exists. In the management of CAUTI in patients with SCI, the use of multiple antibiotics over time in an individual increases the rate of multidrug-resistant organisms; therefore, the exploration of novel non-antibiotic treatments is of importance. The patient experience should be at the center of all these efforts. Conclusion: Better diagnostic tools or biomarkers are needed to define true CAUTI in people with SCI. SCI-specific evidence to inform catheter management and CAUTI treatment guidelines is needed, with the goal to minimize catheter-related harm, reduce antibiotic resistance, and improve satisfaction and overall quality of life for SCI patients.
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Affiliation(s)
- Felicia Skelton-Dudley
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas
| | - James Doan
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas
| | - Katie Suda
- Center for Innovation for Complex Chronic HealthCare (CINCCH), Edward Hines Jr. VA Hospital, Chicago, Illinois
- University of Illinois at Chicago, Chicago, Illinois
| | - S. Ann Holmes
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas
| | - Charlesnika Evans
- Center for Innovation for Complex Chronic HealthCare (CINCCH), Edward Hines Jr. VA Hospital, Chicago, Illinois
- Northwestern University, Department of Preventive Medicine and Center for Health Care Studies, Institute for Public Health and Medicine, Feinberg School of Medicine, Chicago, Illinois
| | - Barbara Trautner
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
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Clark R, Welk B. The ability of prior urinary cultures results to predict future culture results in neurogenic bladder patients. Neurourol Urodyn 2018; 37:2645-2650. [DOI: 10.1002/nau.23713] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Accepted: 04/26/2018] [Indexed: 12/12/2022]
Affiliation(s)
- Roderick Clark
- Department of Surgery (Urology); Western University; London Ontario Canada
| | - Blayne Welk
- Department of Surgery (Urology); Western University; London Ontario Canada
- Department of Epidemiology and Biostatistics; Western University; London Ontario Canada
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Fitzpatrick MA, Suda KJ, Safdar N, Burns SP, Jones MM, Poggensee L, Ramanathan S, Evans CT. Changes in bacterial epidemiology and antibiotic resistance among veterans with spinal cord injury/disorder over the past 9 years. J Spinal Cord Med 2018; 41:199-207. [PMID: 28198662 PMCID: PMC5901456 DOI: 10.1080/10790268.2017.1281373] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
OBJECTIVE Patients with spinal cord injury and disorder (SCI/D) have an increased risk of infection with multidrug-resistant (MDR) bacteria. We described bacterial epidemiology and resistance in patients with SCI/D at Veterans Affairs Medical Centers (VAMCs) for the past 9 years. DESIGN Retrospective cohort. SETTING One hundred thirty VAMCs. PARTICIPANTS Veterans with SCI/D and bacterial cultures with antibiotic susceptibility testing performed between 1/1/2005-12/31/2013. Single cultures with contaminants and duplicate isolates within 30 days of initial isolates were excluded. INTERVENTIONS None. OUTCOMES Trends in microbial epidemiology and antibiotic resistance. RESULTS Included were 216,504 isolates from 19,421 patients. Urine was the most common source and Gram-negative bacteria (GNB) were isolated most often, with 36.1% of GNB being MDR. Logistic regression models clustered by patient and adjusted for location at an SCI/D center and geographic region showed increased odds over time of vancomycin resistance in Enterococcus [adjusted odds ratio (aOR) 1.67, 95% confidence interval (CI) 1.30-2.15], while methicillin resistance in Staphylococcus aureus remained unchanged (aOR 0.90, 95% CI 0.74-1.09). There were also increased odds of fluoroquinolone resistance (aOR 1.39, 95% CI 1.31-1.47) and multidrug resistance (aOR 1.46, 95% CI 1.38-1.55) in GNB, with variability in the odds of MDR bacteria by geographic region. CONCLUSIONS GNB are isolated frequently in Veterans with SCI/D and have demonstrated increasing resistance over the past 9 years. Priority should be given to controlling the spread of resistant bacteria in this population. Knowledge of local and regional epidemiologic trends in antibiotic resistance in patients with SCI/D may improve appropriate antibiotic prescribing.
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Affiliation(s)
- Margaret A. Fitzpatrick
- Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, Hines, Illinois, USA,Department of Medicine, Division of Infectious Diseases, Loyola University Stritch School of Medicine, Maywood, Illinois, USA,Correspondence to: Margaret A. Fitzpatrick, MD, MS, 5000 S. 5th Ave., Hines, IL 60141, USA.
| | - Katie J. Suda
- Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, Hines, Illinois, USA,Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Nasia Safdar
- Department of Veterans Affairs, William S. Middleton VA Medical Center, Madison, Wisconsin, USA,Department of Medicine, Division of Infectious Diseases, University of Wisconsin, Madison, Wisconsin, USA
| | - Stephen P. Burns
- Department of Veterans Affairs, VA Puget Sound Healthcare System, Seattle, Washington, USA,Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Makoto M. Jones
- Department of Veterans Affairs, VA Salt Lake City Healthcare System, Salt Lake City, Utah, USA,Department of Medicine, Division of Epidemiology, University of Utah, Salt Lake City, Utah, USA
| | - Linda Poggensee
- Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, Hines, Illinois, USA
| | - Swetha Ramanathan
- Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, Hines, Illinois, USA
| | - Charlesnika T. Evans
- Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, Hines, Illinois, USA,Center for Healthcare Studies and Department of Preventive Medicine Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Truzzi JC, Teich V, Pepe C. Can hydrophilic coated catheters be beneficial for the public healthcare system in Brazil? - A cost-effectiveness analysis in patients with spinal cord injuries. Int Braz J Urol 2018; 44:121-131. [PMID: 28792195 PMCID: PMC5815542 DOI: 10.1590/s1677-5538.ibju.2017.0221] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 07/17/2017] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Detrusor sphincter dyssynergia affects 70% to 80% of all spinal cord injury patients, resulting in increased risk of urinary tract infections (UTIs) and potential exposure to antimicrobial resistance. In Brazil, local guidelines recommend intermittent catheterization as the best method for bladder emptying, and two catheter types are available: the conventional uncoated PVC and the hydrophilic coated catheters. OBJECTIVE To evaluate the cost-effectiveness of two types of catheters for intermittent catheterization from the perspective of the Brazilian public healthcare system. MATERIALS AND METHODS A Markov model was used to evaluate cost-effectiveness in those with spinal cord injuries. A primary analysis was conducted on all possible adverse events, and a secondary analysis was performed with urinary tract infections as the only relevant parameter. The results were presented as cost per life years gained (LYG), per quality-adjusted life years (QALY) and per number of urinary tract infections (UTIs) avoided. RESULTS The base scenario of all adverse events shows a cost-effective result of hydrophilic coated catheters compared to uncoated PVC catheters at 57,432 BRL (Brazilian Reais) per LYG and 122,330 BRL per QALY. The secondary scenario showed that the use of hydrophilic coated catheters reduces the total number of UTIs, indicating that an additional cost of hydrophilic coated catheters of 31,240 BRL over a lifetime will reduce lifetime UTIs by 6%. CONCLUSIONS Despite the higher unit value, the use of hydrophilic coated catheters is a cost-effective treatment from the perspective of the Brazilian public healthcare system.
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Affiliation(s)
- José Carlos Truzzi
- Escola Paulista de Medicina, Universidade Federal de São Paulo, SP, Brasil
- Hospital Alemão Oswaldo Cruz, São Paulo, SP, Brasil
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Prevalence and Factors Associated With Multidrug-Resistant Gram-Negative Organisms in Patients With Spinal Cord Injury. Infect Control Hosp Epidemiol 2017; 38:1464-1471. [DOI: 10.1017/ice.2017.238] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVEInfections caused by multidrug-resistant gram-negative organisms (MDRGNOs) have been increasing every year. The objective of this study was to describe the prevalence of MDRGNOs and factors associated with MDRGNOs in patients with spinal cord injury or disorder (SCI/D).DESIGNRetrospective cohort study.METHODSDepartment of Veterans Affairs (VA) electronic health record data from 142 VA facilities were evaluated for 19,642 patients with SCI/D. Multivariable cluster-adjusted models were fit to identify factors associated with MDRGNO.RESULTSGram-negative (GN) cultures occurred in 44% of patients with SCI/D receiving care at VA facilities, and 11,527 (41.3%) GN cultures had an MDRGNO. The most frequent GN organisms (GNOs) were Escherichia coli (28.5%), Klebsiella pneumoniae (17.0%), and Pseudomonas aeruginosa (16.0%). Two-thirds of GN cultures were from the outpatient setting, where MDRGNO prevalence was 37.6%. Significant geographic variation in the prevalence of MDRGNOs was identified (South, 44.7%; Northeast, 44.3%; West, 36.8%; Midwest, 34.4%). Other factors associated with an MDRGNO were older age, injury characteristics, comorbidities, specimen type, healthcare setting, and healthcare exposure. Black (odds ratio [OR], 1.58; 95% confidence interval [CI], 1.39–1.78) and Hispanic race (OR, 1.58; 95% CI, 1.28–1.95), polymicrobial culture (OR, 2.67; 95% CI, 2.46–2.90), and antibiotic use in the previous 90 days (OR, 1.62; 95% CI, 1.50–1.76) were also associated with having an MDRGNO.CONCLUSIONSMDRGNOs were common in community and healthcare settings among veterans with SCI/D, with significant geographic variation. Health care and antibiotic exposures were significant factors associated with MDRGNOs. Priority should be given to controlling the spread of MDRGNOs in this special population, including a focus on judicious use of antibiotics.Infect Control Hosp Epidemiol 2017;38:1464–1471
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Multidrug-resistant Acinetobacter: Risk factors and outcomes in veterans with spinal cord injuries and disorders. Am J Infect Control 2017; 45:1183-1189. [PMID: 28757086 DOI: 10.1016/j.ajic.2017.06.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 06/14/2017] [Accepted: 06/15/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Multidrug-resistant (MDR) Acinetobacter is a growing concern and has been identified as a serious threat by the Centers for Disease Control and Prevention. However, there is little information on MDR Acinetobacter in individuals with spinal cord injuries and disorders (SCI/Ds). Therefore, the objective of this study was to identify risk factors for, and assess outcomes of, MDR Acinetobacter in veterans with SCI/Ds. METHODS This was a retrospective cohort study from January 1, 2012-December 31, 2013, using national Veterans Affairs medical encounter and microbiology data. RESULTS A total of 773 Acinetobacter cultures were identified in 571 patients, of which 58.9% were MDR. Inpatient culture, sputum and other specimen type, receipt of antibiotics within 90 days before culture date, and pressure ulcers were identified as independent predictors of MDR Acinetobacter. Highest odds of MDR Acinetobacter were seen with previous antibiotic use (odds ratio, 7.27; 95% confidence interval, 2.59-20.54). Thirty-day mortality was 5.3% in this study. Multidrug resistance, previous mechanical ventilation 90 days before the culture, and cancer were all independent risk factors for 30-day mortality. CONCLUSIONS There should be increased efforts to highlight the importance of antimicrobial stewardship to improve infection control to help limit spread of Acinetobacter in health care settings.
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Routine Urine Testing at the Spinal Cord Injury Annual Evaluation Leads to Unnecessary Antibiotic Use: A Pilot Study and Future Directions. Arch Phys Med Rehabil 2017; 99:219-225. [PMID: 29107038 DOI: 10.1016/j.apmr.2017.10.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 09/06/2017] [Accepted: 10/03/2017] [Indexed: 01/05/2023]
Abstract
OBJECTIVES To measure the prevalence of asymptomatic bacteriuria (ASB) in persons with spinal cord injury (SCI) at the time of their annual examination and to examine the effect on urine testing during the annual examination on subsequent antibiotic use. DESIGN Retrospective cohort study. SETTING A major SCI center. PARTICIPANTS Veterans (N=393) with SCI seen for an outpatient annual evaluation in 2012 or 2013. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Antibiotic use for bacteriuria within 7 days of the annual evaluation encounter. RESULTS There were 327 clinic visits that met inclusion criteria; of these 327 veterans, 249 had a urine culture performed. A total of 171 urine cultures (69%) were positive for bacteria, of which 22 (13%) represented urinary tract infection (UTI) cases and 149 (87%) were ASB cases. More than a third of the ASB cases (n=53 [36%]) were treated with antibiotics. None of the 78 visits with negative urine cultures received antibiotics to treat the UTI; thus, a positive urine culture alone was associated with antibiotic use (P<.01). Factors predicting antibiotic use were higher age, nitrite presence on urinalysis, and urease-producing organism on culture media. When comparing bladder management strategies, indwelling catheterization was found to be associated with higher levels of pyuria and hematuria than did spontaneous voiding or intermittent catheterization (P<.01). CONCLUSIONS Two-thirds of the urine cultures of persons with SCI presenting for their annual examination were positive. Most of the positive cultures represented ASB cases, and more than a third of these were treated with antibiotics. A better understanding of the mandate for urine testing at the annual examination and the outcomes of this practice is an important first step in developing antibiotic stewardship for UTI in persons with SCI.
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Risk factors for community-associated multidrug-resistant Pseudomonas aeruginosa in veterans with spinal cord injury and disorder: a retrospective cohort study. Spinal Cord 2017; 55:687-691. [PMID: 28169292 PMCID: PMC5501739 DOI: 10.1038/sc.2017.7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 12/01/2016] [Accepted: 12/30/2016] [Indexed: 02/06/2023]
Abstract
Study Design Retrospective cohort study Objectives To identify independent risk factors associated with community-associated multidrug resistant P. aeruginosa (MDRPA) in a population of Veterans with spinal cord injury and disorders (SCI/D). Setting 127 Veterans Affairs healthcare facilities Methods Laboratory results from January 1, 2012 to December 31, 2013 were collected and MDRPA cultures were compared to non-MDRPA cultures. Results One thousand four hundred forty one cultures were collected from Veterans with SCI/D, including 227 cultures with MDRPA isolates. Characteristics associated with an increased odds of MDRPA include age 50-64 (aOR= 1.80, 95% CI= 1.13-2.87), MDRPA culture in the past 365 days (aOR= 9.12, 95% CI= 5.88-14.15), and carbapenem exposure in the past 90 days (aOR= 2.56, 95% CI= 1.35-4.87). In contrast, paraplegia was associated with a 53% decreased odds of MDRPA compared to those with tetraplegia (aOR= 0.47, 95% CI= 0.32-0.69). Conclusions Risk factors for community-associated MDRPA include prior history of MDRPA and exposure to carbapenems. Awareness of these factors is important for targeted prevention and treatment of MDRPA in patients with SCI/D.
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Klebsiella pneumoniae carbapenemase-producing K. pneumoniae (KPC-KP) in brain and spinal cord injury patients: potential for prolonged colonization. Spinal Cord 2016; 55:390-395. [PMID: 27752059 DOI: 10.1038/sc.2016.136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 08/19/2016] [Accepted: 08/22/2016] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES To determine the prevalence of brain and spinal cord injury (BSCI) patients among all patients with Klebsiella pneumoniae carbapenemase-producing K. pneumoniae (KPC-KP) and to evaluate clinical characteristics and duration of colonization. SETTING Tertiary care academic medical center. METHODS Electronic medical records of BSCI patients with KPC-KP from February 2009 to December 2014 were reviewed to determine clinical characteristics. Patients with multiple KPC-KPs were defined as those with isolates in different calendar months, and patients with a single positive isolate were compared with those with repeatedly positive isolates. Variables with a P-value of ⩽0.05 were considered statistically significant. Two archived isolates recovered from separate cultures of the same patient were compared with pulsed-field gel electrophoresis to calculate the duration of colonization. RESULTS Of the 218 patients with KPC-KP, 86 (39%) had BSCI and 27 (31%) had multiple KPC-KPs. The KPC-KPs from 20 (74%) patients with multiple isolates were available for analysis. Patients with repeated positive isolates were more likely to be younger (P=0.05), African American (P=0.05), suffer gunshot injuries (P=0.01) and other trauma (P=0.03) and have decubitus ulcers (P=0.05). Of the 20 patients with multiple isolates for analysis, 13 (65%) patients were colonized with the same strain type over time, and the strain persisted on average 373 days. CONCLUSION BSCI patients comprise a significant percentage of our KPC-KP population. Owing to repeated hospitalizations and prolonged colonization, they represent a substantial reservoir for these multidrug-resistant pathogens.
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