Device-associated infection rates, device utilization, and antimicrobial resistance in long-term acute care hospitals reporting to the National Healthcare Safety Network, 2010

Guidelines for Antibiotics Prescription in Critically Ill Patients

How to cite this article: Khilnani GC, Tiwari P, Mittal S, Kulkarni AP, Chaudhry D, Zirpe KG, et al. Guidelines for Antibiotics Prescription in Critically Ill Patients. Indian J Crit Care Med 2024;28(S2):S104-S216.

Improved Genomic Prediction of Staphylococcus epidermidis Isolation Sources with a Novel Polygenic Score

Staphylococcus epidermidis infections can be challenging to diagnose due to the species frequent contamination of clinical specimens and indolent course of infection. Nevertheless, S. epidermidis is the major cause of late-onset sepsis among premature infants and of intravascular infection in all age groups. Prior work has shown that bacterial virulence factors, antimicrobial resistances, and strains have up to 80% in-sample accuracy to distinguish hospital from community sources, but are unable to distinguish true bacteremia from blood culture contamination. Here, a phylogeny-informed genome-wide association study of 88 isolates was used to estimate effect sizes of particular genomic variants for isolation sources. A "polygenic score" was calculated for each isolate as the summed effect sizes of its repertoire of genomic variants. Predictive models of isolation sources based on polygenic scores were tested with in-samples and out-samples from prior studies of different patient populations. Polygenic scores from accessory genes (AGs) distinguished hospital from community sources with the highest accuracy to date, up to 98% for in-samples and 65% to 91% for various out-samples, whereas scores from single nucleotide polymorphisms (SNPs) had lower accuracy. Scores from AGs and SNPs achieved the highest in-sample accuracy to date, up to 76%, in distinguishing infection from contaminant sources within a hospital. Model training and testing data sets with more similar population structures resulted in more accurate predictions. This study reports the first use of a polygenic score for predicting a complex bacterial phenotype and shows the potential of this approach for enhancing S. epidermidis diagnosis.

Development and validation of a user-friendly risk nomogram for the prediction of catheter-associated urinary tract infection in neuro-intensive care patients

OBJECTIVE

This study aimed to develop a user-friendly nomogram model to evaluate the risk of catheter-associated urinary tract infections in neuro-critically ill patients.

METHODS

A retrospective cohort analysis was conducted on 537 patients with indwelling catheters admitted to the neuro-intensive care unit. Patients' general information, laboratory examination findings, and clinical characteristics were collected. Multivariate regression analysis was applied to develop the nomogram for the prediction of catheter-associated urinary tract infections in this group of patients. The discriminative capacity, calibration ability, and clinical effectiveness of the nomogram were evaluated.

RESULTS

The occurrence of catheter-associated urinary tract infections was 3.91 % and Escherichia coli was the major causative pathogen. Multivariate regression analysis showed that age ≥ 60 years (odds ratio: 35.2, 95 % confidence interval: 2.3-550.8), epilepsy (39.3, 5.1-301.4), a length of neuro-intensive care stay > 30 days (272.2, 8.3-8963.5), and low albumin levels (<35 g/L) (12.1, 2.1-69.9) were independent risk factors associated with catheter-associated urinary tract infection in neuro-intensive care patients. The nomogram demonstrated good calibration and discrimination in both the training and the validation sets. The model exhibited good clinical use since the decision curve analysis covered a large threshold probability.

CONCLUSIONS

We developed a user-friendly nomogram to predict catheter-associated urinary tract ibfection in neuro-intensive care patients. The nomogram incorporated clinical variables collected on admission (age, admission diagnosis, and albumin levels) and the length of stay and enabled the effective prediction of the likelihood of catheter-associated urinary tract infections.

Predictive Performance of Gram Staining of Catheter Tips for Candida Catheter-Related Bloodstream Infections

We analyzed 2462 episodes of suspected catheter-related bloodstream infection (CRBSI). The sensitivity, specificity, and positive and negative predictive values for detecting Candida CRBSI by gram staining of catheter tips were 66.1%, 99.4%, 84.4%, and 98.4%, respectively. Gram staining may be useful for the early detection of Candida CRBSI.

Urinary Tract Infections: 2021 Update

Catheter-associated urinary tract infection (CAUTI) remains one of the most prevalent, but preventable, health care-associated infections and predominantly occurs in patients with indwelling urinary catheters. Duration of urinary catheterization is the most important modifiable risk factor for development of CAUTI. Alternatives to indwelling catheters should be considered in appropriate patients. If indwelling catheterization is necessary, proper aseptic practices for catheter insertion and maintenance and use of a closed catheter collection system are essential for preventing CAUTI. The use of intervention bundles and collaboratives helps in the effective implementation of CAUTI prevention measures.

Trends of central line-associated bloodstream infections in the intensive care unit in the Kingdom of Bahrain: Four years’ experience

BACKGROUND

The central venous line is an essential component in monitoring and managing critically ill patients. However, it poses patients with increased risks of severe infections with a higher probability of morbidity and mortality.

AIM

To define the trends of the rates of central line-associated bloodstream infections (CLABSI) over four years, its predicted risk factors, aetiology, and the antimicrobial susceptibility of the isolated pathogens.

METHODS

The study was a prospective case-control study, performed according to the guidelines of the Center for Disease Control surveillance methodology for CLABSI in patients admitted to the adult intensive care unit (ICU) and auditing the implementation of its prevention bundle.

RESULTS

Thirty-four CLABSI identified over the study period, giving an average CLABSI rate of 3.2/1000 central line days. The infection's time trend displayed significant reductions over time concomitantly with the CLABSI prevention bundle's reinforcement from 4.7/1000 central line days at the beginning of 2016 to 1.4/1000 central line days by 2018. The most frequently identified pathogens causing CLABSI in our ICU were gram-negative organisms (59%). The most common offending organisms were Acinetobacter, Enterococcus, and Staphylococcus epidermidis, each of them accounted for 5 cases (15%). Multidrug-resistant organisms contributed to 56% of CLABSI. Its rate was higher when using femoral access and longer hospitalisation duration, especially in the ICU. Insertion of the central line in the non-ICU setting was another identified risk factor.

CONCLUSION

Implementing the prevention bundles reduced CLABSI significantly in our ICU. Implementing the CLABSI prevention bundle is crucial to maintain a substantial reduction in the CLABSI rate in the ICU setting.

Ventilator-associated pneumonia in patients on prolonged mechanical ventilation: description, risk factors for mortality, and performance of the SOFA score

Objective:

Ventilator-associated pneumonia (VAP) is a serious complication of mechanical ventilation (MV). However, data on VAP in patients on prolonged MV (PMV) are scarce. We aimed to describe the characteristics of VAP patients on PMV and to identify factors associated with mortality.

Methods:

This was a retrospective cohort study including VAP patients on PMV. We recorded baseline characteristics, as well as 30-day and 90-day mortality rates. Variables associated with mortality were determined by Kaplan-Meier survival analysis and Cox regression model.

Results:

We identified 80 episodes of VAP in 62 subjects on PMV. The medians for age, Charlson Comorbidity Index, SOFA score, and days on MV were, respectively, 69.5 years, 5, 4, and 56 days. Episodes of VAP occurred between days 21 and 50 of MV in 28 patients (45.2%) and, by day 90 of MV, in 48 patients (77.4%). The 30-day and 90-day mortality rates were 30.0% and 63.7%, respectively. There were associations of 30-day mortality with the SOFA score (hazard ratio [HR] = 1.30; 95% CI: 1.12-1.52; p < 0.001) and use of vasoactive agents (HR = 4.0; 95% CI: 1.2-12.9; p = 0.02), whereas 90-day mortality was associated with age (HR = 1.03; 95% CI: 1.00-1.05; p = 0.003), SOFA score (HR = 1.20; 95% CI: 1.07-1.34; p = 0.001), use of vasoactive agents (HR = 4.07; 95% CI: 1.93-8.55; p < 0.001), and COPD (HR = 3.35; 95% CI: 1.71-6.60; p < 0.001).

Conclusions:

Mortality rates in VAP patients on PMV are considerably high. The onset of VAP can occur various days after MV initiation. The SOFA score is useful for predicting fatal outcomes. The factors associated with mortality could help guide therapeutic decisions and determine prognosis.

Comparative effectiveness of long-term acute care hospital versus skilled nursing facility transfer

Background

Long-term acute care hospital (LTACH) use varies considerably across the U.S., which may reflect uncertainty about the effectiveness of LTACHs vs. skilled nursing facilities (SNF), the principal post-acute care alternative. Given that LTACHs provide more intensive care and thus receive over triple the reimbursement of SNFs for comparable diagnoses, we sought to compare outcomes and spending between LTACH versus SNF transfer.

Methods

Using Medicare claims linked to electronic health record (EHR) data from six Texas Hospitals between 2009 and 2010, we conducted a retrospective cohort study of patients hospitalized on a medicine service in a high-LTACH use region and discharged to either an LTACH or SNF and followed for one year. The primary outcomes included mortality, 60-day recovery without inpatient care, days at home, and healthcare spending

Results

Of 3503 patients, 18% were transferred to an LTACH. Patients transferred to LTACHs were younger (median 71 vs. 82 years), less likely to be female (50.5 vs 66.6%) and white (69.0 vs. 84.1%), but were sicker (24.3 vs. 14.2% for prolonged intensive care unit stay; median diagnosis resource intensity weight of 2.03 vs. 1.38). In unadjusted analyses, patients transferred to an LTACH vs. SNF were less likely to survive (59.1 vs. 65.0%) or recover (62.5 vs 66.0%), and spent fewer days at home (186 vs. 200). Adjusting for demographic and clinical confounders available in Medicare claims and EHR data, LTACH transfer was not significantly associated with differences in mortality (HR, 1.12, 95% CI, 0.94–1.33), recovery (SHR, 1.07, 0.93–1.23), and days spent at home (IRR, 0.96, 0.83–1.10), but was associated with greater Medicare spending ($16,689 for one year, 95% CI, $12,216–$21,162).

Conclusion

LTACH transfer for Medicare beneficiaries is associated with similar clinical outcomes but with higher healthcare spending compared to SNF transfer. LTACH use should be reserved for patients who require complex inpatient care and cannot be cared for in SNFs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-05847-6.

The SHIELD Orange County Project: Multidrug-resistant Organism Prevalence in 21 Nursing Homes and Long-term Acute Care Facilities in Southern California

BACKGROUND

Multidrug-resistant organisms (MDROs) spread between hospitals, nursing homes (NHs), and long-term acute care facilities (LTACs) via patient transfers. The Shared Healthcare Intervention to Eliminate Life-threatening Dissemination of MDROs in Orange County is a regional public health collaborative involving decolonization at 38 healthcare facilities selected based on their high degree of patient sharing. We report baseline MDRO prevalence in 21 NHs/LTACs.

METHODS

A random sample of 50 adults for 21 NHs/LTACs (18 NHs, 3 LTACs) were screened for methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus spp. (VRE), extended-spectrum β-lactamase-producing organisms (ESBL), and carbapenem-resistant Enterobacteriaceae (CRE) using nares, skin (axilla/groin), and peri-rectal swabs. Facility and resident characteristics associated with MDRO carriage were assessed using multivariable models clustering by person and facility.

RESULTS

Prevalence of MDROs was 65% in NHs and 80% in LTACs. The most common MDROs in NHs were MRSA (42%) and ESBL (34%); in LTACs they were VRE (55%) and ESBL (38%). CRE prevalence was higher in facilities that manage ventilated LTAC patients and NH residents (8% vs <1%, P < .001). MDRO status was known for 18% of NH residents and 49% of LTAC patients. MDRO-colonized adults commonly harbored additional MDROs (54% MDRO+ NH residents and 62% MDRO+ LTACs patients). History of MRSA (odds ratio [OR] = 1.7; confidence interval [CI]: 1.2, 2.4; P = .004), VRE (OR = 2.1; CI: 1.2, 3.8; P = .01), ESBL (OR = 1.6; CI: 1.1, 2.3; P = .03), and diabetes (OR = 1.3; CI: 1.0, 1.7; P = .03) were associated with any MDRO carriage.

CONCLUSIONS

The majority of NH residents and LTAC patients harbor MDROs. MDRO status is frequently unknown to the facility. The high MDRO prevalence highlights the need for prevention efforts in NHs/LTACs as part of regional efforts to control MDRO spread.

High Prevalence of Multidrug-Resistant Organism Colonization in 28 Nursing Homes: An "Iceberg Effect"

OBJECTIVE

Determine the prevalence of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus spp. (VRE), extended-spectrum beta-lactamase producing organisms (ESBLs), and carbapenem-resistant Enterobacteriaceae (CRE) among residents and in the environment of nursing homes (NHs).

DESIGN

Point prevalence sampling of residents and environmental sampling of high-touch objects in resident rooms and common areas.

SETTING

Twenty-eight NHs in Southern California from 2016 to 2017.

PARTICIPANTS

NH participants in Project PROTECT, a cluster-randomized trial of enhanced bathing and decolonization vs routine care.

METHODS

Fifty residents were randomly sampled per NH. Twenty objects were sampled, including 5 common room objects plus 5 objects in each of 3 rooms (ambulatory, total care, and dementia care residents).

RESULTS

A total of 2797 swabs were obtained from 1400 residents in 28 NHs. Median prevalence of multidrug-resistant organism (MDRO) carriage per NH was 50% (range: 24%-70%). Median prevalence of specific MDROs were as follows: MRSA, 36% (range: 20%-54%); ESBL, 16% (range: 2%-34%); VRE, 5% (range: 0%-30%); and CRE, 0% (range: 0%-8%). A median of 45% of residents (range: 24%-67%) harbored an MDRO without a known MDRO history. Environmental MDRO contamination was found in 74% of resident rooms and 93% of common areas.

CONCLUSIONS AND IMPLICATIONS

In more than half of the NHs, more than 50% of residents were colonized with MDROs of clinical and public health significance, most commonly MRSA and ESBL. Additionally, the vast majority of resident rooms and common areas were MDRO contaminated. The unknown submerged portion of the iceberg of MDRO carriers in NHs may warrant changes to infection prevention and control practices, particularly high-fidelity adoption of universal strategies such as hand hygiene, environmental cleaning, and decolonization.

A Nurse-Led Low-Cost Intervention Effectively Traces Prevalence of Catheter Associated Urinary Tract Infections at a Low-Resourced Regional Referral Hospital in Western Uganda: A Case for Policy Change

Catheter associated urinary tract infection (CAUTI) is the most common hospital-acquired infection worldwide. Low- and middle-income countries (LMICs) with limited resources for health care have not allocated resources to adequately monitor or prevent CAUTIs. The infection is associated with several adverse clinical outcomes, including antibiotic resistance, septicemia, and prolonged hospital stays, that burden the already resource-constrained health systems in LMICs with increased morbidity, health care costs, and deaths. Owing to the lack of resource allocation, little is known about the prevalence of CAUTI in the government-owned and operated hospitals in LIMCs. The purpose of this research was to test a method of CAUTI prevalence surveillance suitable to the resource-constrained health system in a LMIC and to determine the prevalence of CAUTI among hospitalized patients at the study site. In an intermittent 4-week data collection plan, the sample of 68 catheterized adult participants was evaluated for the presence of CAUTI using the three-pronged screening criteria of American Urological Society. CAUTI prevalence in the sample was 17.6%. The high prevalence of CAUTI in this sample represents a substantial risk of consequences to hospitalized patients and to the resource-constrained health system in this LMIC. This first report of CAUTI surveillance using readily available and affordable tools provides evidence to health ministry policymakers of the need for and value of monitoring and prevention programs for hospital-acquired infections in LMICs. We recommend LMIC health policymakers to establish infection prevention teams in hospitals and provide resources to continue surveillance and prevention of CAUTI and other hospital-acquired infections.

Respiratory Practices in the Long-term Care Setting: A Human Factors-Based Risk Analysis

OBJECTIVE

To systematically assess safety risks pertaining to tracheostomy care in the long-term care (LTC) setting using a human factors engineering approach.

DESIGN

We utilized a 5-part approach to complete our proactive risk assessment: (1) performed a hierarchical task analysis of the processes of tracheostomy stoma and suctioning; (2) identified failure modes where a subtask may be completed inappropriately; (3) prioritized each failure mode based on a risk priority scale; (4) identified contributing factors to and consequences for each of the prioritized failure modes; and (5) identified potential solutions to eliminate or mitigate risks.

SETTING

Three high-acuity LTC facilities with ventilator units across Maryland.

METHODS

The hierarchical task analysis was conducted jointly by 2 human-factors experts and an infectious disease physician based on respiratory care policies from the Centers for Disease Control and Prevention and existing policies at each LTC facility. The findings were used to guide direct observations with contextual inquiry and focus group sessions to assess safety risks for residents receiving tracheostomy care.

RESULTS

Direct observations of tracheostomy care and suctioning in the LTC setting revealed significant variations in practice. Respiratory therapists working in LTC reported lack of training and ambiguity concerning recommended procedures to reduce infection transmission in daily care. Highest risk steps identified in tracheostomy care and suctioning included hand hygiene, donning gloves, and providing intermittent suctioning as the suction catheter was withdrawn. Participants identified risk mitigation strategies targeting these high-risk failure modes that addressed contributing factors related to 5 work system components: person (knowledge and competency), task (eg, urgency or time constraints), tools and technology (eg, availability of hand sanitizer), environment (eg, communal rooms), and organization (eg, patient safety culture).

CONCLUSIONS AND IMPLICATIONS

Human factors analysis of the highest-risk steps in respiratory care activities in the LTC setting suggest several potential mitigation strategies to decrease the risk of infection transmission. Clear procedure guidelines with training are needed to reduce ambiguity and improve care in this setting. Involving frontline staff in patient safety issues using human factors principles and risk analysis may encourage participation and improve the infection prevention culture in LTC.

Staphylococcus aureus Nasal Carriage and Autoimmune Diseases: From Pathogenic Mechanisms to Disease Susceptibility and Phenotype

The role of infective agents in autoimmune diseases (ADs) development has been historically investigated, but in the last years has been strongly reconsidered due to the interest in the link between the microbiome and ADs. Together with the gut, the skin microbiome is characterized by the presence of several microorganisms, potentially influencing innate and adaptive immune response. S. aureus is one of the most important components of the skin microbiome that can colonize anterior nares without clinical manifestations. Data from the literature demonstrates a significantly higher prevalence of nasal colonization in ADs patients in comparison with healthy subjects, suggesting a possible role in terms of disease development and phenotypes. Thus, in the present narrative review we focused on the mechanisms by which S. aureus could influence the immune response and on its relationship with ADs, in particular granulomatosis with polyangiitis, rheumatoid arthritis, and systemic lupus erythematosus.

Prevalence of Implanted Medical Devices in Medicine Inpatients

Implanted medical devices (IMDs) are extremely common, yet they are not systematically documented on hospital admission. Through structured patient interviews, we determined the prevalence of IMDs in hospital inpatients. Using medical record review, we evaluated the sensitivity of the medical record reporting of IMDs on an academic medical inpatient service. Fifty-eight percent of 191 interviewees reported 1 or more IMDs. Participants who reported greater than 1 IMD were older and had more frequent hospitalizations. The most common devices reported were surgical mesh, screws, plates, or wires (n = 47); intravascular stents (n = 25); and prosthetic joint replacements (n = 17). Forty-six patients (24%) reported greater than 1 IMD that had not been recorded in their admission history and physical examination. The prevalence of IMDs in hospitalized patients is high and underestimated in the medical record and may have significant implications for patient care.

Infections in Cirrhosis

Purpose of review

Patients with cirrhosis are at high risk of developing serious infections. Bacterial infections remain the most common cause of morbidity and mortality in these patients. This review is focused on the prevalence of infections in those with cirrhosis, including multidrug-resistant (MDR) pathogens, pathogenesis of infection-related acute-on-chronic liver failure (ACLF), current treatment recommendations, and prophylactic strategies in patients with cirrhosis.

Recent findings

Recent epidemiological studies have noted an emerging prevalence of MDR bacterial infections and associated with poor prognosis, and a high rate of treatment failure and mortality. Therefore, new recommendations on empirical antibiotic use based on epidemiological data have been developed in order to improve outcomes.

Summary

Spontaneous bacterial peritonitis (SBP) and urinary tract infection (UTI) are the most frequent infections followed by pneumonia, cellulitis, and bacteremia, while pneumonia carries the highest risk of mortality. The incidence of MDR bacterial infections has been increasing, especially in healthcare-associated settings. Second infections that develop during hospitalization, multiple organ failures, and high MELD score are associated with poor survival. Preventive measures, early diagnosis, and adequate treatment of infections are essential key concepts in minimizing morbidity and mortality in patients with cirrhosis.

Long-Term Acute Care Hospital Use of Non-Mechanically Ventilated Hospitalized Older Adults

OBJECTIVES

To determine why non-mechanically ventilated hospitalized older adults are transferred to long-term acute care (LTAC) hospitals rather than remaining in the hospital.

DESIGN

Observational cohort.

SETTING

National Medicare data.

PARTICIPANTS

Non-mechanically ventilated hospitalized adults aged 65 and older with fee-for-service Medicare in 2012 who were transferred to an LTAC hospital (n=1,831) or had a prolonged hospitalization without transfer (average hospital length of stay or longer of those transferred to an LTAC hospital) and had one of the 50 most common hospital diagnoses leading to LTAC transfer (N=12,875).

MEASUREMENTS

We assessed predictors of transfer using a multilevel model, adjusting for patient-, hospital-, and hospital referral region (HRR)-level factors. We estimated proportions of variance at each level and adjusted hospital- and HRR-specific LTAC transfer rates using sequential models.

RESULTS

The strongest predictor of transfer was being hospitalized near an LTAC hospital (<1.4 vs > 33.6 miles, adjusted odds ratio=6.2, 95% confidence interval (CI)=4.2-9.1). After adjusting for case mix, differences between hospitals explained 15.4% of the variation in LTAC use and differences between regions explained 27.8%. Case mix-adjusted LTAC use was high in the South, where many HRRs had rates between 20.3% and 53.1%, whereas many HRRs were less than 5.4% in the Pacific Northwest, North, and New England. From our fully adjusted model, the median adjusted hospital LTAC transfer rate was 7.2% (interquartile range 2.8-17.5%), with substantial within-region variation (intraclass coefficient=0.25, 95% CI=0.21-0.30).

CONCLUSIONS

Nearly half of the variation in LTAC use is independent of illness severity and is explained by which hospital and what region the individual was hospitalized in. Because of the greater fragmentation of care and Medicare spending with LTAC transfers (because LTAC hospitals generate a separate bundled payment from the hospital), greater attention is needed to define the optimal role of LTAC hospitals in caring for older adults. J Am Geriatr Soc 66:2112-2119, 2018.

Outpatient Parenteral Therapy for Complicated Staphylococcus aureus Infections: A Snapshot of Processes and Outcomes in the Real World

Background

In the United States, patients discharged on outpatient parenteral antimicrobial therapy (OPAT) are often treated by home health companies (HHCs) or skilled nursing facilities (SNFs). Little is known about differences in processes and outcomes between these sites of care.

Methods

We performed a retrospective study of 107 patients with complicated Staphylococcus aureus infections discharged on OPAT from 2 academic medical centers. Clinical characteristics, site of posthospital care, process measures (lab test monitoring, clinic follow-up), adverse events (adverse drug events, Clostridium difficile infection, line events), and clinical outcomes at 90 days (cure, relapse, hospital readmission) were collected. Comparisons between HHCs and SNFs were conducted.

Results

Overall, 33% of patients experienced an adverse event during OPAT, and 64% were readmitted at 90 days. Labs were received for 44% of patients in SNFs and 56% of patients in HHCs. At 90 days after discharge, a higher proportion of patients discharged to an SNF were lost to follow-up (17% vs 3%; P = .03) and had line-related adverse events (18% vs 2%; P < .01). Patients discharged to both sites of care experienced similar clinical outcomes, with favorable outcomes occurring in 61% of SNF patients and 70% of HHC patients at 90 days. There were no differences in rates of relapse, readmission, or mortality.

Conclusions

Patients discharged to SNFs may be at higher risk for line events than patients discharged to HHCs. Efforts should be made to strengthen basic OPAT processes, such as lab monitoring and clinic follow-up, at both sites of care.

Impact of a Multidisciplinary Infection Prevention Initiative on Central Line and Urinary Catheter Utilization in a Long-term Acute Care Hospital

Background

Prolonged central line (CL) and urinary catheter (UC) use can increase risk of central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI).

Methods

This interventional study conducted in a 76-bed long-term acute care hospital (LTACH) in Southeast Michigan was divided into 3 periods: pre-intervention (January 2015-June 2015), intervention (July-November 2015), and postintervention (December 2015-March 2017). During the intervention period, a multidisciplinary infection prevention team (MIPT) made weekly recommendations to remove unnecessary CL/UC or switch to alternate urinary/intravenous access. Device utilization ratios (DURs) and infection rates were compared between the study periods. Interrupted time series (ITS) and 0-inflated poisson (ZIP) regression were used to analyze DUR and CLABSI/CAUTI data, respectively.

Results

UC-DUR was 31% in the pre- and postintervention periods and 21% in the intervention period. CL-DUR decreased from 46% (pre-intervention) to 39% (intervention) to 37% (postintervention). The results of ITS analysis indicated nonsignificant decrease and increase in level/trend in DURs coinciding with our intervention. The CAUTI rate per catheter-days did not decrease during intervention (4.36) compared with pre- (2.49) and postintervention (1.93). The CLABSI rate per catheter-days decreased by 73% during intervention (0.39) compared with pre-intervention (1.45). Rates again quadrupled postintervention (1.58). ZIP analysis indicated a beneficial effect of intervention on infection rates without reaching statistical significance.

Conclusions

We demonstrated that a workable MIPT initiative focusing on removal of unnecessary CL and UC can be easily implemented in an LTACH requiring minimal time and resources. A rebound increase in UC-DURs to pre-intervention levels after intervention end indicates that continued vigilance is required to maintain performance.

Factors Associated With Variation in Long-term Acute Care Hospital vs Skilled Nursing Facility Use Among Hospitalized Older Adults

IMPORTANCE

Despite providing an overlapping level of care, it is unknown why hospitalized older adults are transferred to long-term acute care hospitals (LTACs) vs less costly skilled nursing facilities (SNFs) for postacute care.

OBJECTIVE

To examine factors associated with variation in LTAC vs SNF transfer among hospitalized older adults.

DESIGN, SETTING, AND PARTICIPANTS

We conducted this retrospective observational cohort study of hospitalized older adults (≥65 years) transferred to an LTAC vs SNF during fiscal year 2012 using national 5% Medicare data.

MAIN OUTCOMES AND MEASURES

Predictors of LTAC transfer were assessed using a multilevel mixed-effects model adjusting for patient-, hospital-, and region-level factors. We estimated variation partition coefficients and adjusted hospital- and region-specific LTAC transfer rates using sequential models.

RESULTS

Among 65 525 hospitalized older adults (42 461 [64.8%] women; 39 908 [60.9%] ≥85 years) transferred to an LTAC or SNF, 3093 (4.7%) were transferred to an LTAC. We identified 29 patient-, 3 hospital-, and 5 region-level independent predictors. The strongest predictors of LTAC transfer were receiving a tracheostomy (adjusted odds ration [aOR], 23.8; 95% CI, 15.8-35.9) and being hospitalized in close proximity to an LTAC (0-2 vs >42 miles; aOR, 8.4, 95% CI, 6.1-11.5). After adjusting for case-mix, differences between patients explained 52.1% (95% CI, 47.7%-56.5%) of the variation in LTAC use. The remainder was attributable to hospital (15.0%; 95% CI, 12.3%-17.6%), and regional differences (32.9%; 95% CI, 27.6%-38.3%). Case-mix adjusted LTAC use was very high in the South (17%-37%) compared with the Pacific Northwest, North, and Northeast (<2.2%). From the full multilevel model, the median adjusted hospital LTAC transfer rate was 2.1% (10th-90th percentile, 0.24%-10.8%). Even within a region, adjusted hospital LTAC transfer rates varied substantially (intraclass correlation coefficient [ICC], 0.26; 95% CI, 0.23-0.30).

CONCLUSIONS AND RELEVANCE

Although many patient-level factors were associated with LTAC use, half of the variation in LTAC vs SNF transfer is independent of patients' illness severity or clinical complexity, and is explained by where the patient was hospitalized and in what region, with far greater use in the South. Even among hospitals in regions with similar LTAC access, there was considerable variation in LTAC use. Given the higher expense associated with LTACs vs SNFs, greater attention is needed to define the optimal role of LTACs in the postacute care of older adults.

Evaluating the Impact of Antibiotic Exposures as Time-Dependent Variables on the Acquisition of Carbapenem-Resistant Acinetobacter baumannii

OBJECTIVES

To determine the time-dependent effect of antibiotics on the initial acquisition of carbapenem-resistant Acinetobacter baumannii.

DESIGN

Retrospective cohort study.

SETTING

Forty-bed trauma ICU in Miami, FL.

PATIENTS

All consecutive patients admitted to the unit from November 1, 2010, to November 30, 2011.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients underwent surveillance cultures at admission to the unit and weekly thereafter. The primary outcome was the acquisition of carbapenem-resistant A. baumannii on surveillance cultures. Daily antibiotic exposures during the time of observation were used to construct time-dependent variables, including cumulative exposures (in grams and daily observed doses [defined daily doses]). Among 360 patients, 45 (12.5%) became colonized with carbapenem-resistant A. baumannii. Adjusted Cox models showed that each additional point in the Acute Physiologic and Chronic Health Evaluation score increased the hazard by 4.8% (hazard ratio, 1.048; 95% CI, 1.010-1.087; p = 0.0124) and time-dependent exposure to carbapenems quadrupled the hazard (hazard ratio, 4.087; 95% CI, 1.873-8.920; p = 0.0004) of acquiring carbapenem-resistant A. baumannii. Additionally, adjusted Cox models determined that every additional carbapenem defined daily dose increased the hazard of acquiring carbapenem-resistant A. baumannii by 5.1% (hazard ratio, 1.051; 95% CI, 1.007-1.093; p = 0.0243).

CONCLUSIONS

Carbapenem exposure quadrupled the hazards of acquiring A. baumannii even after controlling for severity of illness.

A highly efficient, low-toxic, wide-spectrum antibacterial coating designed for 3D printed implants with tailorable release properties

A broad spectrum antibacterial coatings with tailorable release properties were developed for 3D printed implants.

External Collection Devices as an Alternative to the Indwelling Urinary Catheter: Evidence-Based Review and Expert Clinical Panel Deliberations

Multiple evidence-based guidelines have suggested clinicians consider external collection devices (ECD) as alternatives to indwelling catheters. Nevertheless, there is a dearth of evidence-based resources concerning their use. An expert consensus panel was convened to review the current state of the evidence, indications for ECDs as an alternative to an indwelling urinary catheter, identify knowledge gaps, and areas for future research. This article presents the results of the expert consensus panel meeting and a systematic literature review regarding ECD use in the clinical setting.

How and when nurses collect urine cultures on catheterized patients: A survey of 5 hospitals

BACKGROUND

Obtaining a specimen for urine culture is a key element in evaluating for catheter-associated urinary tract infections (CAUTIs). Evaluating nurses' knowledge regarding appropriate reasons and methods to obtain urine culture specimens are the first steps to improving practice.

METHODS

Nurses at 5 hospitals completed a 40-question survey regarding their knowledge, training, and practices of appropriate reasons for obtaining urine cultures. The survey included different scenarios of patients with urinary catheters and when they would expect to obtain urine cultures. A 12-point scoring system calculated responses regarding urine collection appropriateness.

RESULTS

There were 394 nurses who responded to the survey. Of them, 76.1% reported receiving education on CAUTI risk reduction within the last 12 months. Although 327 (83%) of all nurses surveyed reported that they never collect urine samples by draining directly from the drainage bag, only 58.4% viewed others to be fully compliant with that standard (P < .001). Nurses who considered their knowledge to be above average to excellent had similar knowledge assessment scores (out of 12 points) for triggers to obtain urine cultures (mean score, 4.9 ± 1.72) compared with those that reported average to poor knowledge (mean score, 4.64 ± 1.78; P = .15).

CONCLUSIONS

Important opportunities exist for nurses to optimize the decisions to obtain urine cultures and the process for obtaining them. Addressing nurses' knowledge and practice may lead to more appropriate use of urine cultures.

Staphylococcus aureus infections: epidemiology, pathophysiology, clinical manifestations, and management

Staphylococcus aureus is a major human pathogen that causes a wide range of clinical infections. It is a leading cause of bacteremia and infective endocarditis as well as osteoarticular, skin and soft tissue, pleuropulmonary, and device-related infections. This review comprehensively covers the epidemiology, pathophysiology, clinical manifestations, and management of each of these clinical entities. The past 2 decades have witnessed two clear shifts in the epidemiology of S. aureus infections: first, a growing number of health care-associated infections, particularly seen in infective endocarditis and prosthetic device infections, and second, an epidemic of community-associated skin and soft tissue infections driven by strains with certain virulence factors and resistance to β-lactam antibiotics. In reviewing the literature to support management strategies for these clinical manifestations, we also highlight the paucity of high-quality evidence for many key clinical questions.

Nationwide study on the use of intravascular catheters in internal medicine departments

BACKGROUND

The use of intravascular catheters (IVCs) in intensive care units (ICUs) has been well assessed in recent years. However, a high proportion of these devices are placed in patients outside the ICU, particularly in internal medicine departments (IMDs), where data on the quality of care are scarce.

AIM

To assess the use and management of IVCs in IMDs in Spain.

METHODS

We performed a point prevalence study of all adult inpatients on 47 IMDs from hospitals of different sizes on one day in June 2013. A local co-ordinator was appointed to assess patients and collect data from each site.

FINDINGS

Out of the 2080 adult patients hospitalized on the study day, 1703 (81.9%) had one or more IVCs (95.4% of which were peripheral devices). Infection was detected at the insertion site in 92 catheters (5.0%); 87 patients (5.2%) had signs of sepsis, but only one case was considered to be catheter-related. The local co-ordinators estimated that 19% of the catheters in place were no longer necessary. A daily record of the need for a catheter was available in only 40.6% of cases.

CONCLUSION

Our study shows clear opportunities for improvement regarding catheter use and care in Spanish IMDs. Strategies similar to those applied in ICUs should be implemented in IMDs.

Antibiotic modulation of capsular exopolysaccharide and virulence in Acinetobacter baumannii

Acinetobacter baumannii is an opportunistic pathogen of increasing importance due to its propensity for intractable multidrug-resistant infections in hospitals. All clinical isolates examined contain a conserved gene cluster, the K locus, which determines the production of complex polysaccharides, including an exopolysaccharide capsule known to protect against killing by host serum and to increase virulence in animal models of infection. Whether the polysaccharides determined by the K locus contribute to intrinsic defenses against antibiotics is unknown. We demonstrate here that mutants deficient in the exopolysaccharide capsule have lowered intrinsic resistance to peptide antibiotics, while a mutation affecting sugar precursors involved in both capsule and lipopolysaccharide synthesis sensitizes the bacterium to multiple antibiotic classes. We observed that, when grown in the presence of certain antibiotics below their MIC, including the translation inhibitors chloramphenicol and erythromycin, A. baumannii increases production of the K locus exopolysaccharide. Hyperproduction of capsular exopolysaccharide is reversible and non-mutational, and occurs concomitantly with increased resistance to the inducing antibiotic that is independent of the presence of the K locus. Strikingly, antibiotic-enhanced capsular exopolysaccharide production confers increased resistance to killing by host complement and increases virulence in a mouse model of systemic infection. Finally, we show that augmented capsule production upon antibiotic exposure is facilitated by transcriptional increases in K locus gene expression that are dependent on a two-component regulatory system, bfmRS. These studies reveal that the synthesis of capsule, a major pathogenicity determinant, is regulated in response to antibiotic stress. Our data are consistent with a model in which gene expression changes triggered by ineffectual antibiotic treatment cause A. baumannii to transition between states of low and high virulence potential, which may contribute to the opportunistic nature of the pathogen.

Acinetobacter baumannii has gained notoriety as a cause of hospital-acquired infections that are difficult to treat due to extensive antibiotic resistance. While the microorganism rarely causes disease in the community, it commonly infects patients receiving antibiotics. The factors intrinsic to the bacterium that enable growth in the presence of antibiotics are not well characterized. Furthermore, the consequences of subinhibitory antibiotic concentrations on A. baumannii disease are unknown. Here we examined the K locus, a bacterial disease determinant responsible for the production of protective surface polysaccharides, and asked whether this determinant also contributes to antibiotic resistance. We found that K locus polysaccharides facilitate resistance to multiple antibiotics, and, unexpectedly, that the bacterium responds to certain antibiotics at subinhibitory concentrations by increasing production of capsule, the principal K locus polysaccharide. This augmented production of capsule, which is mediated by upregulation of K locus gene expression, increased the ability of the bacterium to overcome attack by the complement system, an important anti-pathogen host defense, and result in lethal disease during experimental bloodstream infection in mice. Our studies indicate that A. baumannii increases its disease-causing potential in the setting of inadequate antibiotic treatment, which may promote the development of opportunistic infections.

Risk factors for catheter-associated urinary tract infection in Italian elderly

BACKGROUND

Catheter-associated urinary tract infections (CAUTIs) are the most common cause of hospital-acquired infections, especially in elderly patients. Data on CAUTIs in older persons in acute care settings are lacking, however. This study aimed to describe the epidemiology of CAUTIs and related outcomes (ie, length of stay and mortality), in patients admitted to an acute geriatric care hospital in central Italy.

METHODS

A CAUTI surveillance program was implemented from October 2011 to April 2012, according to the Centers for Disease Control and Prevention's National Healthcare Safety Network methodology.

RESULTS

A total of 2773 patients aged ≥65 years were included in the study, and 483 catheterized patients were monitored for the risk of CAUTI. The catheterization rate was 16.7% (95% confidence interval [CI], 15.3%-18.2%), and the overall CAUTI incidence rate was 14.7/1000 device-days (95% CI, 11.7-18.3/1000). Mortality was significantly higher in catheterized patients with a CAUTI compared with noncatheterized patients (19.2% vs 10.5%; P < .05). Female sex (odds ratio [OR], 1.31; 95% CI, 1.06-1.67), increasing age (≥90 years: OR, 2.76; 95% CI, 2.00-3.83), and longer hospital stay before catheter insertion (≥15 days: OR, 2.90; 95% CI, 2.20-3.83) were independent risk factors for catheterization; increasing age (>90 years: OR, 2.75; 95% CI, 1.03-7.35), and duration of hospital stay before catheter insertion (OR, 2.41; 95% CI, 1.12-5.51) were associated with CAUTIs.

CONCLUSIONS

These results underscore the importance of the proper choice of patients for catheterization, particularly in individuals aged >90 years.

Antiadhesive polymer brush coating functionalized with antimicrobial and RGD peptides to reduce biofilm formation and enhance tissue integration

This paper describes the synthesis and characterization of polymer-peptide conjugates to be used as infection-resistant coating for biomaterial implants and devices. Antiadhesive polymer brushes composed of block copolymer Pluronic F-127 (PF127) were functionalized with antimicrobial peptides (AMP), able to kill bacteria on contact, and arginine-glycine-aspartate (RGD) peptides to promote the adhesion and spreading of host tissue cells. The antiadhesive and antibacterial properties of the coating were investigated with three bacterial strains: Staphylococcus aureus, Staphylococcus epidermidis, and Pseudomonas aeruginosa. The ability of the coating to support mammalian cell growth was determined using human fibroblast cells. Coatings composed of the appropriate ratio of the functional components: PF127, PF127 modified with AMP, and PF127 modified with RGD showed good antiadhesive and bactericidal properties without hampering tissue compatibility.

Long-term catheterization: current approaches in the diagnosis and treatment of port-related infections

Since the first description in 1982, totally implanted venous access ports have progressively improved patients' quality of life and medical assistance when a medical condition requires the use of long-term venous access. Currently, they are part of the standard medical care for oncohematologic patients. However, apart from mechanical and thrombotic complications, there are also complications associated with biofilm development inside the catheters. These biofilms increase the cost of medical assistance and extend hospitalization. The most frequently involved micro-organisms in these infections are gram-positive cocci. Many efforts have been made to understand biofilm formation within the lumen catheters, and to resolve catheter-related infection once it has been established. Apart from systemic antibiotic treatment, the use of local catheter treatment (ie, antibiotic lock technique) is widely employed. Many different antimicrobial options have been tested, with different outcomes, in clinical and in in vitro assays. The stability of antibiotic concentration in the lock solution once instilled inside the catheter lumen remains unresolved. To prevent infection, it is mandatory to perform hand hygiene before catheter insertion and manipulation, and to disinfect catheter hubs, connectors, and injection ports before accessing the catheter. At present, there are still unresolved questions regarding the best antimicrobial agent for catheter-related bloodstream infection treatment and the duration of concentration stability of the antibiotic solution within the lumen of the port.

The importance of long-term acute care hospitals in the regional epidemiology of Klebsiella pneumoniae carbapenemase-producing Enterobacteriaceae

BACKGROUND

In the United States, Klebsiella pneumoniae carbapenemase (KPC)-producing Enterobacteriaceae are increasingly detected in clinical infections; however, the colonization burden of these organisms among short-stay and long-term acute care hospitals is unknown.

METHODS

Short-stay acute care hospitals with adult intensive care units (ICUs) in the city of Chicago were recruited for 2 cross-sectional single-day point prevalence surveys (survey 1, July 2010-January 2011; survey 2, January-July 2011). In addition, all long-term acute care hospitals (LTACHs) in the Chicago region (Cook County) were recruited for a single-day point prevalence survey during January-May 2011. Swab specimens were collected from rectal, inguinal, or urine sites and tested for Enterobacteriaceae carrying blaKPC.

RESULTS

We surveyed 24 of 25 eligible short-stay acute care hospitals and 7 of 7 eligible LTACHs. Among LTACHs, 30.4% (119 of 391) of patients were colonized with KPC-producing Enterobacteriaceae, compared to 3.3% (30 of 910) of short-stay hospital ICU patients (prevalence ratio, 9.2; 95% confidence interval, 6.3-13.5). All surveyed LTACHs had patients harboring KPC (prevalence range, 10%-54%), versus 15 of 24 short-stay hospitals (prevalence range, 0%-29%). Several patient-level covariates present at the time of survey-LTACH facility type, mechanical ventilation, and length of stay-were independent risk factors for KPC-producing Enterobacteriaceae colonization.

CONCLUSIONS

We identified high colonization prevalence of KPC-producing Enterobacteriaceae among patients in LTACHs. Patients with chronic medical care needs in long-term care facilities may play an important role in the spread of these extremely drug-resistant pathogens.