Variability in Emergency Medicine Provider Decisions on Hospital Admission and Antibiotic Treatment in a Survey Study for Acute Bacterial Skin and Skin Structure Infections: Opportunities for Antimicrobial Stewardship Education

The impact of the COVID-19 pandemic on nosocomial infections: a retrospective analysis in a tertiary maternal and child healthcare hospital

Objective

The constant changes in the control strategies of the Corona Virus Disease 2019 (COVID-19) pandemic have greatly affected the prevention and control of nosocomial infections (NIs). This study assessed the impact of these control strategies on the surveillance of NIs in a regional maternity hospital during the COVID-19 pandemic.

Methods

This retrospective study compared the observation indicators of nosocomial infections and their changing trends in the hospital before and during the COVID-19 pandemic.

Results

In total, 2,56,092 patients were admitted to the hospital during the study. During the COVID-19 pandemic, the main drug-resistant bacteria in hospitals were Escherichia coli, Streptococcus agalactiae, Staphylococcus aureus, Klebsiella pneumoniae, and Enterococcus faecalis. The detection rate of S. agalactiae increased annually, while that of E. faecalis remained the same. The detection rate of multidrug-resistant bacteria decreased during the pandemic (16.86 vs. 11.42%), especially that of CRKP (carbapenem-resistant Klebsiella pneumoniae 13.14 vs. 4.39, P < 0.001). The incidence of nosocomial infections in the pediatric surgery department decreased significantly (OR: 2.031, 95% CI: 1.405-2.934, P < 0.001). Regarding the source of infection, a significant reduction was observed in respiratory infections, followed by gastrointestinal infections. In the routine monitoring of the ICU, the incidence of central line-associated bloodstream infection (CLABSI) decreased significantly (9.4/1,000 catheter days vs. 2.2/1,000 catheter days, P < 0.001).

Conclusion

The incidence of nosocomial infections was lower than that before the COVID-19 pandemic. The prevention and control measures for the COVID-19 pandemic have reduced the number of nosocomial infections, especially respiratory, gastrointestinal, and catheter-related infections.

Antimicrobial Stewardship at Transitions of Care to Outpatient Settings: Synopsis and Strategies

Inappropriate antibiotic use and associated consequences, including pathogen resistance and Clostridioides difficile infection, continue to serve as significant threats in the United States, with increasing incidence in the community setting. While much attention has been granted towards antimicrobial stewardship in acute care settings, the transition to the outpatient setting represents a significant yet overlooked area to target optimized antimicrobial utilization. In this article, we highlight notable areas for improved practices and present an interventional approach to stewardship tactics with a framework of disease, drug, dose, and duration. In doing so, we review current evidence regarding stewardship strategies at transitional settings, including diagnostic guidance, technological clinical support, and behavioral and educational approaches for both providers and patients.

Later emergency provider shift hour is associated with increased risk of admission: a retrospective cohort study

BACKGROUND

Understanding factors that drive admissions is critical to containing cost and optimising hospital operations. We hypothesised that, due to multiple factors, emergency physicians would be more likely to admit a patient seen later in their shift.

METHODS

Retrospective study examining all patient visits at a large academic hospital from July 2010 to July 2016. Patients with missing data (n=191) were excluded. 294 031 emergency department (ED) visits were included in the final analysis. The exposure of interest was the time during the shift at which a patient was first evaluated by the clinician, and outcome was hospital admission. We used a generalised estimating equation with physician as the clustering level to adjust for patient age, gender, Emergency Severity Index (ESI, 1=most severe illness, 5=least severe illness) and 24 hours clock time. We also conducted a stratified analysis by three ESI categories.

RESULTS

From the 294 031 ED visits, 5977 were seen in the last hour of the shift. Of patients seen in the last shift hour, 43% were admitted versus 39% seen at any other time during the shift. There was a significant association between being evaluated in the last hour (RR 1.03, 95% CI 1.01 to 1.06) and last quarter (RR 1.02, 1.01 to 1.03) of shift and the likelihood of admission. Patients with an ESI Score of 4-5 saw the largest effect sizes (RR 1.62, 0.996-2.635 for last hour and RR 1.24, 0.996-1.535 for last quarter) but these were not statistically significant. Additionally, there was a trend towards increased likelihood of admission later in shift; the relative risk of admission was 1.04 in hour 6, (1.02-1.05), 1.03 in hour 7 (1.01-1.05), 1.04 in hour 8 (1.01-1.06) and 1.06 in hour 9 (1.013-1.101).

CONCLUSIONS

There is a small but significant association between a patient being evaluated later in an emergency physician's shift and their likelihood of being admitted to the hospital.

Treatment Duration and Associated Outcomes for Skin and Soft Tissue Infections in Patients With Obesity or Heart Failure

Background

Although existing literature supports durations of 5-7 days for skin and soft tissue infections (SSTIs), longer durations are commonly used. Obesity and heart failure (HF) have been associated with increased risk for treatment failure of SSTIs; however, whether prolonged antibiotic durations reduce the risk of treatment failure is unknown. We evaluated practice patterns for SSTIs in patients with obesity and/or HF and whether short antibiotic durations (≤8 days) were associated with treatment failure.

Methods

We performed a single-center, retrospective cohort study of inpatients between January 1, 2006, and December 30, 2016, with SSTIs based on International Classification of Diseases (ICD) coding, and obesity and/or HF. Charts were manually reviewed to collect demographic, clinical, treatment, and outcome data. Propensity score matching was used to estimate the risk of treatment failure between the 2 groups. Secondary outcomes included length of stay, 30-day readmission, and Clostridium difficile infection rates.

Results

A total of 207 patients were included. Forty-nine (23.7%) received a short antibiotic duration and 158 (76.3%) a long duration. The median duration of therapy (interquartile range [IQR]) was 7 (7-8) days in the short group and 14 (10-15) days in the long group. In the propensity score-matched cohort, 28 (28.6%) treatment failures occurred in the long group, as compared with 5 (10.2%) in the short group (P = .02), as well as a shorter length of stay (IQR) in the short- vs long-duration group (2 [2-3] vs 3 [2-5] days, respectively; P = .002). There was no difference in other secondary outcomes.

Conclusions

The majority of patients with obesity or HF received a longer antibiotic course for SSTIs; however, a longer antibiotic course was not associated with lower treatment failure rates. Higher failure rates in the long-duration group may be reflective of clinical decisions made in the face of diagnostic uncertainty and warrant further evaluation.