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Drews FA, Martinello RA, Hebden JN, St John KH, Pegues DA. Disinfection of central venous access device needleless connectors: A human factors analysis. Infect Control Hosp Epidemiol 2024:1-6. [PMID: 38389492 DOI: 10.1017/ice.2024.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
OBJECTIVE Evidence-based central-line-associated bloodstream infection (CLABSI) prevention guidelines recommend the use of an antiseptic scrub to disinfect needleless connectors before device access. Guideline noncompliance may render disinfection ineffective. The goal of this study was to observe needleless-connector disinfection practices and to identify perceived facilitators and barriers to best practices of needleless-connector access. METHODS A human factors mixed-methods study involving nursing focus groups of perceived barriers and facilitators and clinical observations of compliance with instructions and protocols for use of 3.15% chlorhexidine gluconate/70% isopropyl alcohol (CHG/IPA) and 70% isopropyl alcohol (IPA) antisepsis products for central venous access device (CVAD) needleless-connector disinfection was conducted in intensive care units (ICUs) at 2 academic medical centers. RESULTS Access to the antiseptic product and lesser workload were identified as best-practice facilitators. Barriers were the time required per needleless-connector access and knowledge deficits. Of the 48 observed access events, 77% resulted in needleless-connector disinfection. The observed mean needleless-connector scrubbing times when using IPA were substantially below the recommended time. Drying time after product use was negligible. CONCLUSIONS Lack of access to the disinfection product, emergency situations, and high workload were barriers to needleless-connector disinfection. Observed scrubbing and drying times were shorter than recommended, especially for IPA wipes. These needleless-connector disinfection deficits may increase the risk of CLABSI. Ongoing education and periodic competency evaluation of needleless-connector disinfection, improvement of supply management, and staffing workload are required to imbed and sustain best practices. Further study involving a larger sample size in diverse patient populations is warranted.
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Affiliation(s)
- Frank A Drews
- Department of Psychology, University of Utah, Salt Lake City, Utah
| | - Richard A Martinello
- Departments of Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, Connecticut
- Department of Infection Prevention, Yale New Haven Health, New Haven, Connecticut
| | | | | | - David A Pegues
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Harrigan JJ, Hamilton KW, Cressman L, Bilker WB, Degnan KO, David MZ, Tran D, Pegues DA, Dutcher L. Antibiotic Prescribing Patterns for Respiratory Tract Illnesses Following the Conclusion of an Education and Feedback Intervention in Primary Care. Clin Infect Dis 2024:ciad754. [PMID: 38271275 DOI: 10.1093/cid/ciad754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND A study previously conducted in primary care practices found that implementation of an educational session and peer comparison feedback was associated with reduced antibiotic prescribing for respiratory tract diagnoses (RTDs). Here, we assess the long-term effects of this intervention on antibiotic prescribing following cessation of feedback. METHODS RTD encounters were grouped into tiers based on antibiotic prescribing appropriateness: tier 1, almost always indicated; tier 2, possibly indicated; and tier 3, rarely indicated. A χ2 test was used to compare prescribing between 3 time periods: pre-intervention, intervention, and post-intervention (14 months following cessation of feedback). A mixed-effects multivariable logistic regression analysis was performed to assess the association between period and prescribing. RESULTS We analyzed 260 900 RTD encounters from 29 practices. Antibiotic prescribing was more frequent in the post-intervention period than in the intervention period (28.9% vs 23.0%, P < .001) but remained lower than the 35.2% pre-intervention rate (P < .001). In multivariable analysis, the odds of prescribing were higher in the post-intervention period than the intervention period for tier 2 (odds ratio [OR], 1.19; 95% confidence interval [CI]: 1.10-1.30; P < .05) and tier 3 (OR, 1.20; 95% CI: 1.12-1.30) indications but was lower compared to the pre-intervention period for each tier (OR, 0.66; 95% CI: 0.59-0.73 tier 2; OR, 0.68; 95% CI: 0.61-0.75 tier 3). CONCLUSIONS The intervention effects appeared to last beyond the intervention period. However, without ongoing provider feedback, there was a trend toward increased prescribing. Future studies are needed to determine optimal strategies to sustain intervention effects.
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Affiliation(s)
- James J Harrigan
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Keith W Hamilton
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Leigh Cressman
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Warren B Bilker
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Kathleen O Degnan
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Michael Z David
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | | | - David A Pegues
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Lauren Dutcher
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Ziegler MJ, Flores EJ, Epps M, Hopkins K, Glaser L, Mull NK, Pegues DA. Clostridioides difficile dynamic electronic order panel, an effective automated intervention to reduce inappropriate inpatient ordering. Infect Control Hosp Epidemiol 2023; 44:1294-1299. [PMID: 36927512 PMCID: PMC10750561 DOI: 10.1017/ice.2022.254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
BACKGROUND Ordering Clostridioides difficile diagnostics without appropriate clinical indications can result in inappropriate antibiotic prescribing and misdiagnosis of hospital onset C. difficile infection. Manual processes such as provider review of order appropriateness may detract from other infection control or antibiotic stewardship activities. METHODS We developed an evidence-based clinical algorithm that defined appropriateness criteria for testing for C. difficile infection. We then implemented an electronic medical record-based order-entry tool that utilized discrete branches within the clinical algorithm including history of prior C. difficile test results, laxative or stool-softener administration, and documentation of unformed bowel movements. Testing guidance was then dynamically displayed with supporting patient data. We compared the rate of completed C. difficile tests after implementation of this intervention at 5 hospitals to a historic baseline in which a best-practice advisory was used. RESULTS Using mixed-effects Poisson regression, we found that the intervention was associated with a reduction in the incidence rate of both C. difficile ordering (incidence rate ratio [IRR], 0.74; 95% confidence interval [CI], 0.63-0.88; P = .001) and C. difficile-positive tests (IRR, 0.83; 95% CI, 0.76-0.91; P < .001). On segmented regression analysis, we identified a sustained reduction in orders over time among academic hospitals and a new reduction in orders over time among community hospitals. CONCLUSIONS An evidence-based dynamic order panel, integrated within the electronic medical record, was associated with a reduction in both C. difficile ordering and positive tests in comparison to a best practice advisory, although the impact varied between academic and community facilities.
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Affiliation(s)
- Matthew J Ziegler
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Healthcare Epidemiology, Infection Prevention and Control, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Emilia J Flores
- Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, Pennsylvania, Pennsylvania
| | - Mika Epps
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kathleen Hopkins
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Laurel Glaser
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nikhil K Mull
- Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, Pennsylvania, Pennsylvania
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David A Pegues
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Healthcare Epidemiology, Infection Prevention and Control, University of Pennsylvania, Philadelphia, Pennsylvania
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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4
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Patel PK, Advani SD, Kofman AD, Lo E, Maragakis LL, Pegues DA, Pettis AM, Saint S, Trautner B, Yokoe DS, Meddings J. Strategies to prevent catheter-associated urinary tract infections in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol 2023; 44:1209-1231. [PMID: 37620117 DOI: 10.1017/ice.2023.137] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
The intent of this document is to highlight practical recommendations in a concise format designed to assist physicians, nurses, and infection preventionists at acute-care hospitals in implementing and prioritizing their catheter-associated urinary tract infection (CAUTI) prevention efforts. This document updates the Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute-Care Hospitals published in 2014. It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission.
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Affiliation(s)
- Payal K Patel
- Division of Infectious Diseases, Intermountain Health, Salt Lake City, Utah, United States
| | - Sonali D Advani
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, United States
| | - Aaron D Kofman
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, United States
| | - Evelyn Lo
- St. Boniface General Hospital and University of Manitoba, Winnipeg, Manitoba, Canada
| | - Lisa L Maragakis
- Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - David A Pegues
- Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Ann Marie Pettis
- University of Rochester Medicine, Rochester, New York, United States
| | - Sanjay Saint
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, United States
- Department of Medicine and the Center for Clinical Management Research, Veterans' Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, United States
| | - Barbara Trautner
- Department of Internal Medicine, Baylor College of Medicine, Houston, Texas, United States
- Section of Health Services Research and the Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans' Affairs Medical Center, Houston, Texas, United States
| | - Deborah S Yokoe
- University of California San Francisco School of Medicine, UCSF Health-UCSF Medical Center, San Francisco, California, United States
| | - Jennifer Meddings
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, United States
- Department of Medicine and the Center for Clinical Management Research, Veterans' Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, United States
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, United States
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Anesi GL, Degnan K, Dutcher L, Saw S, Maguire C, Binkley A, Patel S, Athans V, Barton TD, Binkley S, Candeloro CL, Herman DJ, Kasbekar N, Kennedy L, Millstein JH, Meyer NJ, Talati NJ, Patel H, Pegues DA, Sayre PJ, Tebas P, Terico AT, Murphy KM, O’Donnell JA, White M, Hamilton KW. The Penn Medicine COVID-19 Therapeutics Committee-Reflections on a Model for Rapid Evidence Review and Dynamic Practice Recommendations During a Public Health Emergency. Open Forum Infect Dis 2023; 10:ofad428. [PMID: 37663091 PMCID: PMC10468749 DOI: 10.1093/ofid/ofad428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 08/08/2023] [Indexed: 09/05/2023] Open
Abstract
The Penn Medicine COVID-19 Therapeutics Committee-an interspecialty, clinician-pharmacist, and specialist-front line primary care collaboration-has served as a forum for rapid evidence review and the production of dynamic practice recommendations during the 3-year coronavirus disease 2019 public health emergency. We describe the process by which the committee went about its work and how it navigated specific challenging scenarios. Our target audiences are clinicians, hospital leaders, public health officials, and researchers invested in preparedness for inevitable future threats. Our objectives are to discuss the logistics and challenges of forming an effective committee, undertaking a rapid evidence review process, aligning evidence-based guidelines with operational realities, and iteratively revising recommendations in response to changing pandemic data. We specifically discuss the arc of evidence for corticosteroids; the noble beginnings and dangerous misinformation end of hydroxychloroquine and ivermectin; monoclonal antibodies and emerging viral variants; and patient screening and safety processes for tocilizumab, baricitinib, and nirmatrelvir-ritonavir.
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Affiliation(s)
- George L Anesi
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Kathleen Degnan
- Division of Infectious Diseases, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Lauren Dutcher
- Division of Infectious Diseases, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Stephen Saw
- Department of Pharmacy, Hospital of the University of Pennsylvania, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Christina Maguire
- Department of Pharmacy, Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Amanda Binkley
- Department of Pharmacy, Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Sonal Patel
- Department of Pharmacy, Hospital of the University of Pennsylvania, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Vasilios Athans
- Department of Pharmacy, Hospital of the University of Pennsylvania, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Todd D Barton
- Division of Infectious Diseases, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Shawn Binkley
- Department of Pharmacy, Hospital of the University of Pennsylvania, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Christina L Candeloro
- Department of Pharmacy, Hospital of the University of Pennsylvania, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - David J Herman
- Division of Infectious Diseases, Penn Medicine Princeton Medical Center, University of Pennsylvania Health System, Princeton, New Jersey, USA
| | - Nishaminy Kasbekar
- Department of Pharmacy, Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Leigh Kennedy
- Division of Infectious Diseases, Pennsylvania Hospital, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Jeffrey H Millstein
- Regional Physician Practices of Penn Medicine, Woodbury Heights, New Jersey, USA
| | - Nuala J Meyer
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Naasha J Talati
- Division of Infectious Diseases, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Hinal Patel
- Department of Pharmacy, Penn Medicine Princeton Medical Center, University of Pennsylvania Health System, Princeton, New Jersey, USA
| | - David A Pegues
- Division of Infectious Diseases, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Patrick J Sayre
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Pablo Tebas
- Division of Infectious Diseases, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Adrienne T Terico
- Department of Pharmacy, Pennsylvania Hospital, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Kathleen M Murphy
- Division of Infectious Diseases, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Judith A O’Donnell
- Division of Infectious Diseases, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Melissa White
- Department of Pharmacy, Penn Medicine Lancaster General Health, University of Pennsylvania Health System, Lancaster, Pennsylvania, USA
| | - Keith W Hamilton
- Division of Infectious Diseases, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Talbot BM, Jacko NF, Petit RA, Pegues DA, Shumaker MJ, Read TD, David MZ. Unsuspected Clonal Spread of Methicillin-Resistant Staphylococcus aureus Causing Bloodstream Infections in Hospitalized Adults Detected Using Whole Genome Sequencing. Clin Infect Dis 2022; 75:2104-2112. [PMID: 35510945 DOI: 10.1093/cid/ciac339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 04/11/2022] [Accepted: 04/27/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Though detection of transmission clusters of methicillin-resistant Staphylococcus aureus (MRSA) infections is a priority for infection control personnel in hospitals, the transmission dynamics of MRSA among hospitalized patients with bloodstream infections (BSIs) has not been thoroughly studied. Whole genome sequencing (WGS) of MRSA isolates for surveillance is valuable for detecting outbreaks in hospitals, but the bioinformatic approaches used are diverse and difficult to compare. METHODS We combined short-read WGS with genotypic, phenotypic, and epidemiological characteristics of 106 MRSA BSI isolates collected for routine microbiological diagnosis from inpatients in 2 hospitals over 12 months. Clinical data and hospitalization history were abstracted from electronic medical records. We compared 3 genome sequence alignment strategies to assess similarity in cluster ascertainment. We conducted logistic regression to measure the probability of predicting prior hospital overlap between clustered patient isolates by the genetic distance of their isolates. RESULTS While the 3 alignment approaches detected similar results, they showed some variation. A gene family-based alignment pipeline was most consistent across MRSA clonal complexes. We identified 9 unique clusters of closely related BSI isolates. Most BSIs were healthcare associated and community onset. Our logistic model showed that with 13 single-nucleotide polymorphisms, the likelihood that any 2 patients in a cluster had overlapped in a hospital was 50%. CONCLUSIONS Multiple clusters of closely related MRSA isolates can be identified using WGS among strains cultured from BSI in 2 hospitals. Genomic clustering of these infections suggests that transmission resulted from a mix of community spread and healthcare exposures long before BSI diagnosis.
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Affiliation(s)
- Brooke M Talbot
- Graduate School of Biological and Biomedical Sciences, Emory University, Atlanta, Georgia, USA
| | - Natasia F Jacko
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert A Petit
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
| | - David A Pegues
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Margot J Shumaker
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Timothy D Read
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Michael Z David
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Harrigan JJ, Hamilton KW, Cressman L, Bilker WB, Degnan K, Tran D, David MZ, Pegues DA, Dutcher L. 1654. Analysis of Prescribing Patterns for Respiratory Tract Illnesses Following the Conclusion of an Education and Feedback Intervention. Open Forum Infect Dis 2022. [PMCID: PMC9752415 DOI: 10.1093/ofid/ofac492.120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background We previously conducted a study in primary care practices assessing the impact of an educational session paired with peer comparison feedback on antibiotic prescribing, demonstrating a reduction in overall prescribing for respiratory tract diseases (RTDs). However, the lasting effects of this intervention on antibiotic prescribing patterns without ongoing feedback are unknown. Methods To study the long-term effects of this feedback on antibiotic prescribing, we analyzed prescribing trends for 14 months after the initial study. We collected encounter-level data, including patient and provider information, ICD-10 codes, and antibiotics prescribed. RTDs were grouped into tiers based on prescribing appropriateness: tier 1 (almost always indicated), tier 2 (may be indicated), and tier 3 (rarely indicated). A χ2 test was used to compare proportions of antibiotic prescribing between three time periods: pre-intervention, intervention, and post-intervention (following cessation of provider feedback). A mixed-effects multivariable logistic regression analysis was performed to assess the association between the period and antibiotic prescribing. Results We analyzed 260,900 encounters (127,324 pre-intervention, 58,431 during the intervention, and 75,145 post-intervention) from 28 practices, with patient, provider and practice characteristics in Table 1. Rates of antibiotic prescribing for RTD visits were higher in the post-intervention period than the intervention period (28.9% vs 23.0%, p< 0.001), but remained lower than the 35.2% pre-intervention rate (Figure 1, p< 0.001). In multivariable analyses, the odds of receiving a prescription was higher in the post-intervention compared to the intervention period for tier 2 (OR 1.19, 95% CI 1.10–1.30, p< 0.05) and tier 3 (OR 1.20, 95% CI 1.12–1.30) indications, but was still lower when compared to the pre-intervention period for each tier (OR 0.66, 95% CI 0.59–0.73 for tier 2; OR 0.68, 95% CI 0.61–0.75 for tier 3) (Table 2).
Table 1 includes patient, provider, and encounter level demographics. Table 2 includes the results of the multivariable analysis. Figure 1 is a graph of proportion of encounters with an antibiotic prescribed over time. The time period associated with the intervention is highlighted and graphs are separated by tier of appropriateness of antibiotic prescribing associated with the encounter. Conclusion The effects of this targeted educational and feedback program last beyond the intervention period, but without ongoing provider feedback there is a trend toward increased prescribing. Future studies are needed to determine optimal strategies to maintain the efficacy of this intervention. Disclosures Kathleen Degnan, MD, Gilead: Grant/Research Support Michael Z. David, MD PhD, Contrafect: Grant/Research Support|GSK: Advisor/Consultant|Johnson and Johnson: Advisor/Consultant.
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Affiliation(s)
- James J Harrigan
- University of the Hospital of Pennsylvania, Philadelphia, Pennsylvania
| | - Keith W Hamilton
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | | | - Warren B Bilker
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Kathleen Degnan
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - David Tran
- Independent Contractor, Philadelphia, Pennsylvania
| | - Michael Z David
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - David A Pegues
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania for the Centers for Disease Control and Prevention (CDC) Epicenters Program
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Ziegler MJ, Babcock H, Babcock H, Welbel SF, Warren DK, Trick W, Reddy S, Tolomeo PC, Omorogbe J, Garcia D, Habrock-Bach T, Donceras OT, Gaynes SM, Cressman L, Burnham JP, Pegues DA, Lautenbach E, Han J. 3. Stopping Hospital Infections with Environmental Services (SHINE): A Cluster-Randomized Trial of Intensive Monitoring Methods for Terminal Room Cleaning on Rates of Multidrug-Resistant Organisms (MDROs) in the Intensive Care Unit (ICU). Open Forum Infect Dis 2021. [PMCID: PMC8644556 DOI: 10.1093/ofid/ofab466.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background MDROs frequently contaminate hospital environments. We performed a multicenter cluster-randomized, crossover trial of two methods for intensive monitoring of terminal cleaning effectiveness at reducing infection and colonization with MDROs within ICUs. Methods Six medical and surgical ICUs at three medical centers received both intensive monitoring interventions sequentially, in a randomized order. The intervention included surveying a minimum of 10 surfaces each in 5 rooms weekly, after terminal cleaning, with adenosine triphosphate (ATP) monitoring or an ultraviolet fluorescent marker (UV/F). Results were delivered to environmental services (EVS) staff in real-time, with failing surfaces recleaned. The primary study outcome was the monthly rate of infection or colonization with MDROs, including methicillin-resistant Staphylococcus aureus, Clostridioides difficile, vancomycin-resistant Enterococcus, and multidrug-resistant gram-negative bacilli (MDR-GNB), assessed during a 12-month baseline comparison period and sequential 6-month intervention periods, separated by a 2-month washout. Outcomes during each intervention period were compared to the combined baseline period plus the alternative intervention period using mixed-effects Poisson regression, with study hospital as a random effect. Results The primary outcome rate varied by hospital and ICU (Figure 1). The ATP method was associated with a relative reduction in the incidence rate of infection or colonization with MDROs (incidence rate ratio (IRR) 0.887, 95% confidence-interval (CI) 0.811–0.969, P=0.008) (Table 1), infection with MDROs (IRR 0.924, 95% CI 0.855–0.998, P=0.04), and infection or colonization limited to multidrug-resistant MDR-GNB (IRR 0.856, 95% CI 0.825–0.887, P< 0.001). The UV/F intervention was not associated with a statistically significant impact on these outcomes. Room turn-around time was increased by a median of one minute with the ATP intervention and 4.5 minutes with the UV/F intervention compared to baseline. ![]()
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Conclusion Intensive monitoring of ICU terminal room cleaning with an ATP modality is associated with a relative reduction of infection and colonization with MDROs with a negligible impact on TAT. Disclosures Hilary Babcock, MD, MPH, FIDSA, FSHEA (nothing to disclose), David K. Warren, MD, MPH, Homburg & Partner (consultant), Ebbing Lautenbach, MD, MPH, MSCE (nothing to disclose), Jennifer Han, MD, MSCE, GlaxoSmithKline (employee, shareholder).
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Affiliation(s)
| | | | | | | | | | - William Trick
- Cook County Health and Rush University Medical Center, Chicago, IL
| | - Sujan Reddy
- Centers for Disease Control and Prevention, Atlanta, GA
| | | | | | | | | | | | | | - Leigh Cressman
- University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Jason P Burnham
- Washington University in St. Louis School of Medicine, St. Louis, MO
| | - David A Pegues
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Zhang HL, Kelly B, David MZ, Lautenbach E, Huang E, Bekele S, Tolomeo PC, Reesey EC, Loughrey S, Pegues DA, Ziegler MJ. 419. SARS-CoV-2 Environmental Surface Contamination of Healthcare Staff Common Areas. Open Forum Infect Dis 2021. [PMCID: PMC8643905 DOI: 10.1093/ofid/ofab466.619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background There are limited data regarding SARS-CoV-2 (SC2) environmental contamination in staff areas of healthcare settings. We performed environmental sampling of staff areas in wards where coronavirus disease 19 (COVID-19) patients received care and compared findings to surfaces within COVID-19 patient rooms. Methods The study was conducted at the Hospital of the University of Pennsylvania (Philadelphia, PA) from 9/15/20-1/26/21. Sampling of 20cm2 surfaces in staff common areas (breakroom high-touch surfaces comprising tables and microwave/refrigerator handles; bathroom surfaces comprising toilet, sink, and doorknob; and floors), nurse workstations (computer mice and floors), and COVID-19 patient rooms (high-touch surfaces comprising bedrail, computer mice/keyboards, and doorknobs; bathroom surfaces; and floors) was performed using flocked swabs one or more times per week. Specimens underwent RNA extraction and quantitative real-time polymerase chain reaction to detect the SC2 N1 region. Median comparisons were performed using Wilcoxon rank sum test. Trends in odds were evaluated using Score test. Results Proportions of surface specimens with detectable SC2 RNA are summarized in Table 1. Median copy numbers were lower among staff toilets compared to COVID-19 patient toilets (135.6 vs. 503.8 copies/specimen, p=0.02), lower among staff breakroom compared to patient room high-touch surfaces (104.3 vs. 220.3 copies/specimen, p=0.007), and similar between staff and patient room samples from sinks and floors. At nurse workstations, SC2 RNA was detected among 22/177 (12.4%) computer mouse and 147/178 (82.6%) floor samples. Odds of SC2 detection increased by study week among common area (p< 0.001) and nurse workstation samples (p< 0.001) (Figures 1 and 2). Table 1. SARS-CoV-2 (SC2) RNA detection on staff common area and coronavirus disease 19 (COVID-19) patient room surfaces at the Hospital of the University of Pennsylvania, 9/15/20-1/26/21. ![]()
Figure 1. Proportion of environmental surface specimens with detectable SARS-CoV-2 RNA from a) staff common areas and b) nurse workstations of inpatient wards where coronavirus disease-19 patients received care at the Hospital of the University of Pennsylvania, 9/15/20-1/26/21. ![]()
Figure 2. Proportion of environmental surface specimens with detectable SARS-CoV-2 RNA in staff common areas of inpatient wards where coronavirus disease-19 patients received care at the Hospital of the University of Pennsylvania, 9/15/20-1/26/21, by surface type: a) staff breakroom surfaces, b) staff bathroom surfaces, c) staff common area floors. ![]()
Conclusion A low prevalence of detectable SC2 RNA was observed among staff area high-touch surfaces; however, the likelihood of detection increased over time. Environmental SC2 RNA detection may reflect primary contamination from infected healthcare workers or secondary contamination from contact with infected patients, though a direct relationship between surface SC2 RNA viral detection and transmission risk has not been established. Disclosures Michael Z. David, MD PhD, GSK (Board Member) Ebbing Lautenbach, MD, MPH, MSCE, Merck (Other Financial or Material Support, Member of Data and Safety Monitoring Board (DSMB))
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Affiliation(s)
- Helen L Zhang
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Brendan Kelly
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | | | | | | | | | | | - Emily C Reesey
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | - David A Pegues
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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10
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Azarian T, Cella E, Baines SL, Shumaker MJ, Samel C, Jubair M, Pegues DA, David MZ. Genomic Epidemiology and Global Population Structure of Exfoliative Toxin A-Producing Staphylococcus aureus Strains Associated With Staphylococcal Scalded Skin Syndrome. Front Microbiol 2021; 12:663831. [PMID: 34489877 PMCID: PMC8416508 DOI: 10.3389/fmicb.2021.663831] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 07/22/2021] [Indexed: 11/30/2022] Open
Abstract
Staphylococci producing exfoliative toxins are the causative agents of staphylococcal scalded skin syndrome (SSSS). Exfoliative toxin A (ETA) is encoded by eta, which is harbored on a temperate bacteriophage ΦETA. A recent increase in the incidence of SSSS in North America has been observed; yet it is largely unknown whether this is the result of host range expansion of ΦETA or migration and emergence of established lineages. Here, we detail an outbreak investigation of SSSS in a neonatal intensive care unit, for which we applied whole-genome sequencing (WGS) and phylogenetic analysis of Staphylococcus aureus isolates collected from cases and screening of healthcare workers. We identified the causative strain as a methicillin-susceptible S. aureus (MSSA) sequence type 582 (ST582) possessing ΦETA. To then elucidate the global distribution of ΦETA among staphylococci, we used a recently developed tool to query extant bacterial WGS data for biosamples containing eta, which yielded 436 genomes collected between 1994 and 2019 from 32 countries. Applying population genomic analysis, we resolved the global distribution of S. aureus with lysogenized ΦETA and assessed antibiotic resistance determinants as well as the diversity of ΦETA. The population is highly structured with eight dominant sequence clusters (SCs) that generally aligned with S. aureus ST clonal complexes. The most prevalent STs included ST109 (24.3%), ST15 (13.1%), ST121 (10.1%), and ST582 (7.1%). Among strains with available data, there was an even distribution of isolates from carriage and disease. Only the SC containing ST121 had significantly more isolates collected from disease (69%, n = 46) than carriage (31%, n = 21). Further, we identified 10.6% (46/436) of strains as methicillin-resistant S. aureus (MRSA) based on the presence of mecA and the SCCmec element. Assessment of ΦETA diversity based on nucleotide identity revealed 27 phylogroups, and prophage gene content further resolved 62 clusters. ΦETA was relatively stable within lineages, yet prophage variation is geographically structured. This suggests that the reported increase in incidence is associated with migration and expansion of existing lineages, not the movement of ΦETA to new genomic backgrounds. This revised global view reveals that ΦETA is diverse and is widely distributed on multiple genomic backgrounds whose distribution varies geographically.
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Affiliation(s)
- Taj Azarian
- Burnett School of Biomedical Sciences, University of Central Florida, Orlando, FL, United States
| | - Eleonora Cella
- Burnett School of Biomedical Sciences, University of Central Florida, Orlando, FL, United States
| | - Sarah L Baines
- Department of Microbiology and Immunology, The University of Melbourne at The Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia
| | - Margot J Shumaker
- Division of Infectious Diseases, University of Pennsylvania, Philadelphia, PA, United States
| | - Carol Samel
- Department of Healthcare Epidemiology, Infection Prevention and Control, University of Pennsylvania, Philadelphia, PA, United States
| | - Mohammad Jubair
- Burnett School of Biomedical Sciences, University of Central Florida, Orlando, FL, United States
| | - David A Pegues
- Division of Infectious Diseases, University of Pennsylvania, Philadelphia, PA, United States.,Department of Healthcare Epidemiology, Infection Prevention and Control, University of Pennsylvania, Philadelphia, PA, United States
| | - Michael Z David
- Division of Infectious Diseases, University of Pennsylvania, Philadelphia, PA, United States
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11
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Dutcher L, Degnan K, Adu-Gyamfi AB, Lautenbach E, Cressman L, David MZ, Cluzet V, Szymczak JE, Pegues DA, Bilker W, Tolomeo P, Hamilton KW. Improving Outpatient Antibiotic Prescribing for Respiratory Tract Infections in Primary Care; a Stepped-Wedge Cluster Randomized Trial. Clin Infect Dis 2021; 74:947-956. [PMID: 34212177 DOI: 10.1093/cid/ciab602] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Inappropriate antibiotic prescribing is common in primary care (PC), particularly for respiratory tract diagnoses (RTDs). However, the optimal approach for improving prescribing remains unknown. METHODS We conducted a stepped-wedge study in PC practices within a health system to assess the impact of a provider-targeted intervention on antibiotic prescribing for RTDs. RTDs were grouped into tiers based on appropriateness of antibiotic prescribing: tier 1 (almost always indicated), tier 2 (may be indicated), and tier 3 (rarely indicated). Providers received education on appropriate RTD prescribing followed by monthly peer comparison feedback on antibiotic prescribing for (1) all tiers and (2) tier 3 RTDs. Chi-squared testing was used to compare the proportion of visits with antibiotic prescriptions before and during the intervention. Mixed-effects multivariable logistic regression analysis was performed to assess the association between the intervention and antibiotic prescribing. RESULTS Across 30 PC practices and 185,755 total visits, overall antibiotic prescribing was reduced with the intervention, from 35.2% to 23.0% of visits (p<0.001). In multivariable analysis, the intervention was associated with a reduced odds of antibiotic prescription for tiers 2 (OR 0.57; 95% CI 0.52 - 0.62) and 3 (OR 0.57; 95% CI 0.53 - 0.61), but not for tier 1 (OR 0.98; 95% CI 0.83 - 1.16). CONCLUSION A provider-focused intervention reduced overall antibiotic prescribing for RTDs without affecting prescribing for infections that likely require antibiotics. Future research should examine the sustainability of such interventions, potential unintended adverse effects on patient health or satisfaction, and provider perceptions and acceptability.
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Affiliation(s)
- Lauren Dutcher
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Kathleen Degnan
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Ebbing Lautenbach
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Leigh Cressman
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Michael Z David
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Valerie Cluzet
- Division of Infectious Diseases, Health Quest, Poughkeepsie, NY, USA
| | - Julia E Szymczak
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - David A Pegues
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Warren Bilker
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Pam Tolomeo
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Keith W Hamilton
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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12
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Fang FC, Benson CA, del Rio C, Edwards KM, Fowler VG, Fredricks DN, Limaye AP, Murray BE, Naggie S, Pappas PG, Patel R, Paterson DL, Pegues DA, Petri WA, Schooley RT. COVID-19-Lessons Learned and Questions Remaining. Clin Infect Dis 2021; 72:2225-2240. [PMID: 33104186 PMCID: PMC7797746 DOI: 10.1093/cid/ciaa1654] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Indexed: 12/13/2022] Open
Abstract
In this article, the editors of Clinical Infectious Diseases review some of the most important lessons they have learned about the epidemiology, clinical features, diagnosis, treatment and prevention of SARS-CoV-2 infection and identify essential questions about COVID-19 that remain to be answered.
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Affiliation(s)
- Ferric C Fang
- Departments of Laboratory Medicine and Pathology, Microbiology, and Medicine, University of Washington School of Medicine, Seattle, WA USA
| | - Constance A Benson
- Department of Medicine, University of California, San Diego School of Medicine, San Diego, CA USA
| | - Carlos del Rio
- Departments of Medicine and Global Health, Emory University School of Medicine, Atlanta, GA USA
| | - Kathryn M Edwards
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN USA
| | - Vance G Fowler
- Department of Medicine, Duke University School of Medicine, Durham, NC USA
| | - David N Fredricks
- Department of Medicine, Fred Hutchinson Cancer Research Center, Seattle, WA USA
| | - Ajit P Limaye
- Departments of Laboratory Medicine and Pathology, Microbiology, and Medicine, University of Washington School of Medicine, Seattle, WA USA
| | - Barbara E Murray
- Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, TX USA
| | - Susanna Naggie
- Department of Medicine, Duke University School of Medicine, Durham, NC USA
| | - Peter G Pappas
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL USA
| | - Robin Patel
- Departments of Laboratory Medicine and Pathology, and Medicine, Mayo Clinic, Rochester, MN USA
| | - David L Paterson
- Department of Medicine, University of Queensland Centre for Clinical Research, Herston, QLD Australia
| | - David A Pegues
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA USA
| | - William A Petri
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA USA
| | - Robert T Schooley
- Department of Medicine, University of California, San Diego School of Medicine, San Diego, CA USA
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13
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Read TD, Jacko NF, Petit RA, Pegues DA, David MZ. 852. Genomic Clusters of Methicillin-Resistant Staphylococcus aureus (MRSA) Causing Bloodstream Infections (BSIs) in Hospitalized Adults, 2018-19. Open Forum Infect Dis 2020. [PMCID: PMC7777327 DOI: 10.1093/ofid/ofaa439.1041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background MRSA BSIs have 15-50% mortality and are commonly diagnosed in US hospitals. However, the frequency of hospital transmission of MRSA causing BSI is unknown. Methods We performed Illumina shotgun whole genome sequencing (WGS) of 106 sequential MRSA isolates from different adults with a BSI at two Philadelphia academic hospitals in a single health system in July 2018-June 2019. We abstracted clinical data from the electronic medical record. Genomic data were analyzed preliminarily using the Staphopia Analysis Pipeline. Results Among 106 subjects, 51.9% were male, 47.2% were white, 46.2% were black, 23.6% were < 40 years of age, and mean age was 53.1 years (s.d. 17 years). One isolate had WGS data that were inadequate for analysis. Of 105 genomes, 52 were clonal cluster (CC) 8, 22 were sequence type (ST) 5, and 16 were ST105; the remaining 15 strains belonged to 8 other CCs. Of CC8 strains, 44 were USA300 and 6 were USA500. There were 6 clusters (i.e., < 35 SNP differences in the core genome) among the 105 isolates. Four clusters were CC5 and two were CC8 strains. One cluster of CC5 strains involved 3 subjects, and 5 clusters involved 2 subjects. One cluster of ST8/USA300 strains were separated by only 1 SNP (Fig a). This and two other clustered pairs were from subjects who had overlapping hospital stays. Two of these paired subjects had an overlap in the same unit while the third pair was in the hospital together on a number of occasions (total of 40 days overlap) but never simultaneously in the same unit. The other three clustered pairs did not have temporally overlapping hospital stays, suggesting transmission via a hospital reservoir. One of these three pairs had hospitalizations overlapping in time, one at each study hospital, before each of them had infections with the related MRSA strains. There was not a clear-cut clustering of SNP distances among the isolate genomes into transmission and non-transmission groups, with some pairs of patient isolates separated by 40-80 SNPs (Fig. b). Figure 1. ![]()
Conclusion We were able to discern from WGS data alone that some MRSA BSIs in 2 hospitals were likely due to strains transmitted between patients. Universal WGS of BSI strains may detect MRSA outbreaks in real time, even in the absence of overlapping hospitalizations, and is an emerging strategy to detect healthcare transmission of MRSA. Disclosures Michael Z. David, MD PhD, GSK (Consultant)
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Affiliation(s)
| | | | | | - David A Pegues
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Michael Z David
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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14
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Escobar DJ, Pegues DA. How Nurses Can Educate the “Thoughtless Person Playing with Penicillin”. Jt Comm J Qual Patient Saf 2020; 46:605-607. [DOI: 10.1016/j.jcjq.2020.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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15
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Dutcher LS, Degnan K, Lautenbach E, Pegues DA, David MZ, Cluzet V, Cressman L, Bilker W, Tolomeo PC, Adu-Gyamfi AB, Hamilton KW. 2067. Improving Outpatient Antimicrobial Prescribing for Respiratory Tract Infections. Open Forum Infect Dis 2019. [PMCID: PMC6809163 DOI: 10.1093/ofid/ofz360.1747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background Antimicrobial stewardship often focuses on inpatients, yet inappropriate antimicrobial use is common in the outpatient setting. We performed a prospective, stepped wedge interventional study to assess the impact of an educational and feedback-based intervention on prescribing practices for respiratory tract infections (RTIs) in the adult primary care ambulatory setting. Methods Family and internal medicine practices were randomly placed into 6 cohorts, which received the intervention in a stepped wedge fashion at monthly intervals. The study period was July 1, 2016 to October 31, 2018, with the intervention occurring from October 1, 2017 to October 31, 2018. The intervention consisted of a 20-minute in-person educational session on appropriate antimicrobial prescribing for RTIs followed by monthly feedback to individual providers on their proportion of antibiotic prescriptions in comparison to their peers for (1) visits with a primary diagnosis of any RTI and (2) visits with a primary diagnosis of an RTI for which an antibiotic should rarely be prescribed (tier 3 diagnoses). The outcome of interest was whether an antibiotic was prescribed in RTI visits. Chi squared testing and logistic regression were used for analysis. Results Thirty-two practices participated, with 197,814 unique visits with a primary RTI diagnosis. Of these, 141,888 (71.7%) were physician visits and 55,926 (28.3%) were advanced practitioner visits (Figure 1). The proportion of visits with antibiotic prescriptions dropped from 37.2% to 24.0% following the intervention (P < 0.0001). Antibiotic prescriptions were significantly reduced for all primary RTI visits, OR 0.53 (95% CI 0.52 to 0.54), as well as for visits with tier 3 RTI diagnoses, OR 0.64 (95% CI 0.60 to 0.68). The proportion of visits with antibiotic prescriptions also exhibited a marked seasonal variation, another finding of the study (Figure 2). Conclusion An educational intervention with provider feedback successfully reduced antibiotic prescribing for RTIs in the ambulatory setting. Additional study is necessary to assess the sustainability of response over time after discontinuation of the monthly feedback. ![]()
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Disclosures All authors: No reported disclosures.
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Affiliation(s)
| | - Kathleen Degnan
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - David A Pegues
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | - Leigh Cressman
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Warren Bilker
- University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pam C Tolomeo
- University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Keith W Hamilton
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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16
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Weingart MF, Vecker R, Fitzpatrick R, Lautenbach E, Pegues DA, Kelly BJ. 2105. Electronic Records of Daily Subglottic Suctioning Predict Infectious and Non-infectious Adverse Ventilator-Associated Events During Critical Care. Open Forum Infect Dis 2018. [PMCID: PMC6253258 DOI: 10.1093/ofid/ofy210.1761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Mechanical ventilation is a life-sustaining therapy for critically ill patients, but is associated with increased hospital costs and risk for significant complications with poor outcomes. Adverse ventilator-associated events (VAEs) can be broadly divided into infectious (infectious ventilator-associated complication (IVAC) or ventilator-associated pneumonia (VAP)) and non-infectious (ventilator-associated complication (VAC)) types. We sought to identify factors that predict both types, and factors that discriminate risk for infectious vs. noninfectious VAE, using electronic medical record (EMR) data available prior to index event. Methods We evaluated 90 consecutive adverse VAEs in the medical intensive care unit of an academic medical center (January 1, 2013–June 30, 2016) to determine prior patient and care factors that discriminate risk for incident VAE. VAE were defined by surveillance criteria from the CDC. Patient and care data were extracted via the EMR. Results A generalized linear mixed effects model found an increase of 1.1 (95% CI 0.53–1.7) subglottic suction events per day (SS/day) on the day before VAE diagnosis, relative to the 4 prior days. Of the 90 VAE included in the study, 41 were infectious (IVAC or VAP), and 49 were labeled ventilator-associated condition (VAC). In the IVAC/VAP group, mean SS/day was 8.0 on the day of VAE diagnosis, 7.5 one day prior, and 6.2 two days prior, compared with 6.6, 6.4, and 5.5 SS/day in the VAC group. Change in antibiotic prescription (87.8% (36) of patients in the IVAC/VAP group vs. 46.9% (23) in the VAC group) (P = 0.023) and acute liver injury (mean AST and ALT 52.9 and 43.6 3 days before IVAC/VAP vs. 1,035.4 and 523.9 before VAC) also differed between the groups (P = 0.0095 and 0.0025). Conclusion Increased daily subglottic suctioning predicts both non-infectious and infectious VAE, but the observed increase is greater prior to IVAC/VAP. Change in antibiotic prescription and acute liver injury also discriminated IVAC/VAP from non-infectious VAE in this small cohort. Disclosures All authors: No reported disclosures.
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Affiliation(s)
- Melanie F Weingart
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Risa Vecker
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rebecca Fitzpatrick
- Infection Control, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ebbing Lautenbach
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - David A Pegues
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brendan J Kelly
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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17
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Ma GK, Pegues DA, Kochman ML, Alby K, Fishman NO, Saunders M, Grous C, Dempsey DT, Ginsberg GG. Implementation of a systematic culturing program to monitor the efficacy of endoscope reprocessing: outcomes and costs. Gastrointest Endosc 2018; 87:104-109.e3. [PMID: 28499830 DOI: 10.1016/j.gie.2017.05.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 05/01/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS In 2015, the U.S. Food and Drug Administration and Centers for Disease Control and Prevention (CDC) issued guidance for duodenoscope culturing and reprocessing in response to outbreaks of carbapenem-resistant Enterobacteriaceae (CRE) duodenoscope-related infections. Based on this guidance, we implemented best practices for reprocessing and developed a systematic process for culturing endoscopes with elevator levers. The aim of this study is to report the outcomes and direct costs of this program. METHODS First, clinical microbiology data from 2011 to 2014 were reviewed retrospectively to assess for possible elevator lever-equipped endoscope-related CRE infections. Second, a program to systematically culture elevator lever-equipped endoscopes was implemented. Each week, about 25% of the inventory of elevator lever-equipped endoscopes is cultured based on the CDC guidelines. If any cultures return bacterial growth, the endoscope is quarantined pending repeat culturing. The costs of the program, including staff time and supplies, have been calculated. RESULTS From 2011 to 2014, none of 17 patients with documented CRE infection had undergone ERCP or endoscopic ultrasound in the previous 36 months. From June 2015 to September 2016, 285 cultures were performed. Three (1.1%) had bacterial growth, 2 with skin contaminants and 1 with an oral contaminant. The associated endoscopes were quarantined and reprocessed, and repeat cultures were negative. The total estimated cost of our program for an inventory of 20 elevator lever-equipped endoscopes was $30,429.60 per year ($1521.48 per endoscope). CONCLUSIONS This 16-month evaluation of a systematic endoscope culturing program identified a low rate of positive cultures after elevator lever endoscope reprocessing. All positive cultures were with non-enteric microorganisms. The program was of modest cost and identified reprocessing procedures that may have led to a low rate of positive cultures.
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Affiliation(s)
- Gene K Ma
- Gastroenterology Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - David A Pegues
- Infectious Diseases Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Michael L Kochman
- Gastroenterology Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Kevin Alby
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Neil O Fishman
- Infectious Diseases Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Marianne Saunders
- Perioperative Services, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Carolyn Grous
- Perioperative Services, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daniel T Dempsey
- Perioperative Services, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gregory G Ginsberg
- Gastroenterology Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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18
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Reisinger JD, Wojcik A, Jenkins I, Edson B, Pegues DA, Greene L. The Project Protect Infection Prevention Fellowship: A model for advancing infection prevention competency, quality improvement, and patient safety. Am J Infect Control 2017; 45:876-882. [PMID: 28476491 DOI: 10.1016/j.ajic.2017.03.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 03/29/2017] [Accepted: 03/29/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND The Centers for Disease Control and Prevention 2016 Healthcare-Associated Infections (HAI) Progress Report documented no change in catheter-associated urinary tract infections (CAUTIs) between 2009 and 2014. There is a need for investment in additional efforts to reduce HAIs, specifically CAUTI. Quality improvement fellowships are 1 approach to expand the capacity of dedicated leaders and infection prevention champions. METHODS The fellowship used a model that expanded collaboration among disciplines and focused on partnership by recruiting a diverse cohort of fellows and by providing 1-on-1 mentoring to enhance leadership development. The curriculum supported the Association for Professionals in Infection Control and Prevention Competency Model in 2 domains: leadership and performance improvement and implementation science. RESULTS The fellowship was successful. The fellows and mentors had self-reported high level of satisfaction, fellows' knowledge increased, and they demonstrated leadership, quality improvement, and implementation science competency within the completed capstone projects. CONCLUSIONS A model encompassing diverse educational topics, discussions, workshops, and mentorship can serve as a template for developing infection prevention champions. Although this project focused on CAUTI, this template can be used in a variety of settings and applied to a range of other HAIs and performance improvement projects.
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19
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O'Rourke K, Murphy T, Srinivas SK, Pegues DA. Preparing for Emerging Infectious Diseases in the Perinatal Population. J Obstet Gynecol Neonatal Nurs 2017; 47:245-253. [PMID: 28736265 DOI: 10.1016/j.jogn.2017.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2017] [Indexed: 01/10/2023] Open
Abstract
The unprecedented scale of the 2014-2015 Ebola virus outbreak in West Africa and the recent emergence and rapid spread of Zika virus infection and resultant neonatal sequelae show that the geographic range, spread, and effect of emerging infections are unpredictable. Lessons learned from analyzing the response of an academic medical center to care for pregnant women with suspected or confirmed Ebola virus disease can help health care professionals address future threats from emerging infections.
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See I, Chang J, Gualandi N, Buser GL, Rohrbach P, Smeltz DA, Bellush MJ, Coffin SE, Gould JM, Hess D, Hennessey P, Hubbard S, Kiernan A, O’Donnell J, Pegues DA, Miller JR, Magill SS. Clinical Correlates of Surveillance Events Detected by National Healthcare Safety Network Pneumonia and Lower Respiratory Infection Definitions-Pennsylvania, 2011-2012. Infect Control Hosp Epidemiol 2016; 37:818-24. [PMID: 27072043 PMCID: PMC5662932 DOI: 10.1017/ice.2016.74] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To determine the clinical diagnoses associated with the National Healthcare Safety Network (NHSN) pneumonia (PNEU) or lower respiratory infection (LRI) surveillance events DESIGN Retrospective chart review SETTING A convenience sample of 8 acute-care hospitals in Pennsylvania PATIENTS All patients hospitalized during 2011-2012 METHODS Medical records were reviewed from a random sample of patients reported to the NHSN to have PNEU or LRI, excluding adults with ventilator-associated PNEU. Documented clinical diagnoses corresponding temporally to the PNEU and LRI events were recorded. RESULTS We reviewed 250 (30%) of 838 eligible PNEU and LRI events reported to the NHSN; 29 reported events (12%) fulfilled neither PNEU nor LRI case criteria. Differences interpreting radiology reports accounted for most misclassifications. Of 81 PNEU events in adults not on mechanical ventilation, 84% had clinician-diagnosed pneumonia; of these, 25% were attributed to aspiration. Of 43 adult LRI, 88% were in mechanically ventilated patients and 35% had no corresponding clinical diagnosis (infectious or noninfectious) documented at the time of LRI. Of 36 pediatric PNEU events, 72% were ventilator associated, and 70% corresponded to a clinical pneumonia diagnosis. Of 61 pediatric LRI patients, 84% were mechanically ventilated and 21% had no corresponding clinical diagnosis documented. CONCLUSIONS In adults not on mechanical ventilation and in children, most NHSN-defined PNEU events corresponded with compatible clinical conditions documented in the medical record. In contrast, NHSN LRI events often did not. As a result, substantial modifications to the LRI definitions were implemented in 2015. Infect Control Hosp Epidemiol 2016;37:818-824.
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Affiliation(s)
- Isaac See
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
- Epidemic Intelligence Service, Center for Surveillance, Epidemiology and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, GA
| | - Julia Chang
- UCLA Geffen School of Medicine, Los Angeles, CA
| | - Nicole Gualandi
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Genevieve L. Buser
- Epidemic Intelligence Service, Center for Surveillance, Epidemiology and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, GA
- Oregon Health Authority, Portland, OR
| | | | | | | | | | - Jane M. Gould
- St. Christopher’s Hospital for Children, Philadelphia, PA
| | - Debra Hess
- Lancaster General Hospital, Lancaster, PA
| | | | - Sydney Hubbard
- The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Andrea Kiernan
- St. Christopher’s Hospital for Children, Philadelphia, PA
| | | | | | - Jeffrey R. Miller
- Career Epidemiology Field Officer, Office of Public Health Preparedness and Response, CDC, assigned to the Pennsylvania Department of Health, Harrisburg, PA
| | - Shelley S. Magill
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
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Han JH, Sullivan N, Leas BF, Pegues DA, Kaczmarek JL, Umscheid CA. Cleaning Hospital Room Surfaces to Prevent Health Care-Associated Infections: A Technical Brief. Ann Intern Med 2015; 163:598-607. [PMID: 26258903 PMCID: PMC4812669 DOI: 10.7326/m15-1192] [Citation(s) in RCA: 119] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
The cleaning of hard surfaces in hospital rooms is critical for reducing health care-associated infections. This review describes the evidence examining current methods of cleaning, disinfecting, and monitoring cleanliness of patient rooms, as well as contextual factors that may affect implementation and effectiveness. Key informants were interviewed, and a systematic search for publications since 1990 was done with the use of several bibliographic and gray literature resources. Studies examining surface contamination, colonization, or infection with Clostridium difficile, methicillin-resistant Staphylococcus aureus, or vancomycin-resistant enterococci were included. Eighty studies were identified-76 primary studies and 4 systematic reviews. Forty-nine studies examined cleaning methods, 14 evaluated monitoring strategies, and 17 addressed challenges or facilitators to implementation. Only 5 studies were randomized, controlled trials, and surface contamination was the most commonly assessed outcome. Comparative effectiveness studies of disinfecting methods and monitoring strategies were uncommon. Future research should evaluate and compare newly emerging strategies, such as self-disinfecting coatings for disinfecting and adenosine triphosphate and ultraviolet/fluorescent surface markers for monitoring. Studies should also assess patient-centered outcomes, such as infection, when possible. Other challenges include identifying high-touch surfaces that confer the greatest risk for pathogen transmission; developing standard thresholds for defining cleanliness; and using methods to adjust for confounders, such as hand hygiene, when examining the effect of disinfecting methods.
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Affiliation(s)
- Jennifer H. Han
- From Perelman School of Medicine, University of Pennsylvania, and Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, and ECRI Institute–Penn Medicine Evidence-based Practice Center, Plymouth Meeting, Pennsylvania
| | - Nancy Sullivan
- From Perelman School of Medicine, University of Pennsylvania, and Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, and ECRI Institute–Penn Medicine Evidence-based Practice Center, Plymouth Meeting, Pennsylvania
| | - Brian F. Leas
- From Perelman School of Medicine, University of Pennsylvania, and Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, and ECRI Institute–Penn Medicine Evidence-based Practice Center, Plymouth Meeting, Pennsylvania
| | - David A. Pegues
- From Perelman School of Medicine, University of Pennsylvania, and Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, and ECRI Institute–Penn Medicine Evidence-based Practice Center, Plymouth Meeting, Pennsylvania
| | - Janice L. Kaczmarek
- From Perelman School of Medicine, University of Pennsylvania, and Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, and ECRI Institute–Penn Medicine Evidence-based Practice Center, Plymouth Meeting, Pennsylvania
| | - Craig A. Umscheid
- From Perelman School of Medicine, University of Pennsylvania, and Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, and ECRI Institute–Penn Medicine Evidence-based Practice Center, Plymouth Meeting, Pennsylvania
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Calfee DP, Salgado CD, Classen D, Arias KM, Podgorny K, Anderson DJ, Burstin H, Coffin SE, Dubberke ER, Fraser V, Gerding DN, Griffin FA, Gross P, Kaye KS, Klompas M, Lo E, Marschall J, Mermel LA, Nicolle L, Pegues DA, Perl TM, Saint S, Weinstein RA, Wise R, Yokoe DS. Strategies to Prevent Transmission of Methicillin-ResistantStaphylococcus aureusin Acute Care Hospitals. Infect Control Hosp Epidemiol 2015; 29 Suppl 1:S62-80. [DOI: 10.1086/591061] [Citation(s) in RCA: 152] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). Our intent in this document is to highlight practical recommendations in a concise format to assist acute care hospitals in their efforts to prevent transmission of methicillin-resistantStaphylococcus aureus(MRSA). Refer to the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America “Compendium of Strategies to Prevent Healthcare-Associated Infections” Executive Summary, Introduction, and accompanying editorial for additional discussion.1. Burden of HAIs caused by MRSA in acute care facilitiesa. In the United States, the proportion of hospital-associatedS. aureusinfections that are caused by strains resistant to methicillin has steadily increased. In 2004, MRSA accounted for 63% ofS. aureusinfections in hospitals.b. Although the proportion ofS. aureus–associated HAIs among intensive care unit (ICU) patients that are due to methicillin-resistant strains has increased (a relative measure of the MRSA problem), recent data suggest that the incidence of central line–associated bloodstream infection caused by MRSA (an absolute measure of the problem) has decreased in several types of ICUs since 2001. Although these findings suggest that there has been some success in preventing nosocomial MRSA transmission and infection, many patient groups continue to be at risk for such transmission.c. MRSA has also been documented in other areas of the hospital and in other types of healthcare facilities, including those that provide long-term care.
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Lo E, Nicolle L, Classen D, Arias KM, Podgorny K, Anderson DJ, Burstin H, Calfee DP, Coffin SE, Dubberke ER, Fraser V, Gerding DN, Griffin FA, Gross P, Kaye KS, Klompas M, Marschall J, Mermel LA, Pegues DA, Perl TM, Saint S, Salgado CD, Weinstein RA, Wise R, Yokoe DS. Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals. Infect Control Hosp Epidemiol 2015; 29 Suppl 1:S41-50. [DOI: 10.1086/591066] [Citation(s) in RCA: 237] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections. The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their catheter-associated urinary tract infection (CAUTI) prevention efforts. Refer to the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America “Compendium of Strategies to Prevent Healthcare-Associated Infections” Executive Summary and Introduction and accompanying editorial for additional discussion.1. Burden of CAUTIsa. Urinary tract infection is the most common hospital-acquired infection; 80% of these infections are attributable to an indwelling urethral catheter.b. Twelve to sixteen percent of hospital inpatients will have a urinary catheter at some time during their hospital stay.c. The daily risk of acquisition of urinary infection varies from 3% to 7% when an indwelling urethral catheter remains in situ.2. Outcomes associated with CAUTIa. Urinary tract infection is the most important adverse outcome of urinary catheter use. Bacteremia and sepsis may occur in a small proportion of infected patients.b. Morbidity attributable to any single episode of catheterization is limited, but the high frequency of catheter use in hospitalized patients means that the cumulative burden of CAUTI is substantial.c. Catheter use is also associated with negative outcomes other than infection, including nonbacterial urethral inflammation, urethral strictures, and mechanical trauma.
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Lo E, Nicolle LE, Coffin SE, Gould C, Maragakis LL, Meddings J, Pegues DA, Pettis AM, Saint S, Yokoe DS. Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2014; 35:464-79. [PMID: 24709715 DOI: 10.1086/675718] [Citation(s) in RCA: 236] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their catheter-associated urinary tract infection (CAUTI) prevention efforts. This document updates “Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA). the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.
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Affiliation(s)
- Evelyn Lo
- St. Boniface General Hospital and University of Manitoba, Winnipeg, Manitoba, Canada
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Lo E, Nicolle LE, Coffin SE, Gould C, Maragakis LL, Meddings J, Pegues DA, Pettis AM, Saint S, Yokoe DS. Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2014; 35 Suppl 2:S32-S47. [PMID: 25376068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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Pegues DA. Editorial commentary: search, destroy, and confirm: how to maximize the benefit and reduce the unintended consequences of contact precautions for control of methicillin-resistant Staphylococcus aureus. Clin Infect Dis 2013; 57:185-7. [PMID: 23572485 DOI: 10.1093/cid/cit214] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Riley MMS, Suda D, Tabsh K, Flood A, Pegues DA. Reduction of surgical site infections in low transverse cesarean section at a university hospital. Am J Infect Control 2012; 40:820-5. [PMID: 22418608 DOI: 10.1016/j.ajic.2011.12.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2011] [Revised: 12/14/2011] [Accepted: 12/14/2011] [Indexed: 10/28/2022]
Abstract
BACKGROUND We implemented evidence-based interventions to reduce risk of surgical site infection (SSI) following low transverse cesarean section (LTCS). METHODS An observational study was conducted to determine LTCS SSI rates and the impact of infection control interventions at an academic teaching hospital during the period October 2005 to December 2008, including the use of 2% chlorhexidine gluconate (CHG) for surgical skin preparation before LTCS and no-rinse CHG cloths for preoperative skin cleansing. We compared overall and risk strata specific SSI rates and standardized incidence ratios during 4 study periods and estimated cost savings. RESULTS Of 1,844 LTCSs performed, 99 patients were identified with SSI. SSI rates per 100 LTCS declined from 6.27 at baseline and 10.84 during the outbreak period to 5.92 in intervention 1 period and 2.29 in intervention 2 period. Overall, a 63.5% reduction in SSI rate from baseline was achieved by ensuring compliance with SSI prevention guidelines and improving skin antisepsis (P = .003). In intervention 2 period, the standardized incidence ratio was 0.99 compared with 2.64 at baseline and 4.50 during the outbreak period. CONCLUSION A multidisciplinary approach including evidence-based SSI prevention practices, effective infection prevention products, and staff and patient engagement substantially reduced infection risk and improved patient safety following LTCS.
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Pegues DA. ACP Journal Club. Review: Fidaxomicin is better than vancomycin for Clostridium difficile recurrence. Ann Intern Med 2012; 156:JC4-09. [PMID: 22508749 DOI: 10.7326/0003-4819-156-8-201204170-02009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Kelesidis T, Humphries R, Uslan DZ, Pegues DA. Daptomycin nonsusceptible enterococci: an emerging challenge for clinicians. Clin Infect Dis 2011; 52:228-34. [PMID: 21288849 PMCID: PMC8483151 DOI: 10.1093/cid/ciq113] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2010] [Accepted: 11/02/2010] [Indexed: 12/17/2022] Open
Abstract
Daptomycin is the only antibiotic with in vitro bactericidal activity against vancomycin-resistant Enterococcus (VRE) that is approved by the Food and Drug Administration (FDA). Data on the potential emergence of daptomycin nonsusceptibility among enterococci remain limited. We systematically reviewed the published literature for reports of isolates of enterococci that were daptomycin nonsusceptible and assessed the clinical significance and outcome of therapy. Based on susceptibility breakpoints approved by the Clinical Laboratory Standards Institute (CLSI), daptomycin has in vitro activity against >90% of enterococcal isolates. Less than 2% of enterococcal isolates were daptomycin nonsusceptible, with minimum inhibitory concentrations (MICs) >4 μg/mL. The prevalence of nonsusceptibility of VRE isolates to daptomycin may be overestimated due to the spread of clonally related isolates in health care settings. Clinicians should be aware of the possibility of the emergence of daptomycin nonsusceptibility and should closely monitor daptomycin MICs of enterococci isolated during treatment.
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Affiliation(s)
- Theodoros Kelesidis
- Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave., Los Angeles, CA 90095, USA.
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Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA. Guideline for prevention of catheter-associated urinary tract infections 2009. Infect Control Hosp Epidemiol 2010; 31:319-26. [PMID: 20156062 DOI: 10.1086/651091] [Citation(s) in RCA: 581] [Impact Index Per Article: 41.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Carolyn V Gould
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Anderson DJ, Kaye KS, Classen D, Arias KM, Podgorny K, Burstin H, Calfee DP, Coffin SE, Dubberke ER, Fraser V, Gerding DN, Griffin FA, Gross P, Klompas M, Lo E, Marschall J, Mermel LA, Nicolle L, Pegues DA, Perl TM, Saint S, Salgado CD, Weinstein RA, Wise R, Yokoe DS. Strategies to prevent surgical site infections in acute care hospitals. Infect Control Hosp Epidemiol 2009; 29 Suppl 1:S51-61. [PMID: 18840089 DOI: 10.1086/591064] [Citation(s) in RCA: 273] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections. The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals to implement and prioritize their surgical site infection (SSI) prevention efforts. Refer to the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America “Compendium of Strategies to Prevent Healthcare-Associated Infections” Executive Summary and Introduction and accompanying editorial for additional discussion.1. Burden of SSIs as complications in acute care facilities.a. SSIs occur in 2%-5% of patients undergoing inpatient surgery in the United States.b. Approximately 500,000 SSIs occur each year.2. Outcomes associated with SSIa. Each SSI is associated with approximately 7-10 additional postoperative hospital days.b. Patients with an SSI have a 2-11 times higher risk of death, compared with operative patients without an SSI.i. Seventy-seven percent of deaths among patients with SSI are direcdy attributable to SSI.c. Attributable costs of SSI vary, depending on the type of operative procedure and the type of infecting pathogen; published estimates range from $3,000 to $29,000.i. SSIs are believed to account for up to $10 billion annually in healthcare expenditures.1. Definitionsa. The Centers for Disease Control and Prevention National Nosocomial Infections Surveillance System and the National Healthcare Safety Network definitions for SSI are widely used.b. SSIs are classified as follows (Figure):i. Superficial incisional (involving only skin or subcutaneous tissue of the incision)ii. Deep incisional (involving fascia and/or muscular layers)iii. Organ/space
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Marschall J, Mermel LA, Classen D, Arias KM, Podgorny K, Anderson DJ, Burstin H, Calfee DP, Coffin SE, Dubberke ER, Fraser V, Gerding DN, Griffin FA, Gross P, Kaye KS, Klompas M, Lo E, Nicolle L, Pegues DA, Perl TM, Saint S, Salgado CD, Weinstein RA, Wise R, Yokoe DS. Strategies to prevent central line-associated bloodstream infections in acute care hospitals. Infect Control Hosp Epidemiol 2009; 29 Suppl 1:S22-30. [PMID: 18840085 DOI: 10.1086/591059] [Citation(s) in RCA: 315] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections. The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their central line–associated bloodstream infection (CLABSI) prevention efforts. Refer to the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America “Compendium of Strategies to Prevent Healthcare-Associated Infections” Executive Summary and Introduction and accompanying editorial for additional discussion.1. Patients at risk for CLABSIs in acute care facilitiesa. Intensive care unit (ICU) population: The risk of CLABSI in ICU patients is high. Reasons for this include the frequent insertion of multiple catheters, the use of specific types of catheters that are almost exclusively inserted in ICU patients and associated with substantial risk (eg, arterial catheters), and the fact that catheters are frequently placed in emergency circumstances, repeatedly accessed each day, and often needed for extended periods.b. Non-ICU population: Although the primary focus of attention over the past 2 decades has been the ICU setting, recent data suggest that the greatest numbers of patients with central lines are in hospital units outside the ICU, where there is a substantial risk of CLABSI.2. Outcomes associated with hospital-acquired CLABSIa. Increased length of hospital stayb. Increased cost; the non-inflation-adjusted attributable cost of CLABSIs has been found to vary from $3,700 to $29,000 per episode
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Affiliation(s)
- Jonas Marschall
- Washington University School of Medicine, St. Louis, Missouri, USA
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Coffin SE, Klompas M, Classen D, Arias KM, Podgorny K, Anderson DJ, Burstin H, Calfee DP, Dubberke ER, Fraser V, Gerding DN, Griffin FA, Gross P, Kaye KS, Lo E, Marschall J, Mermel LA, Nicolle L, Pegues DA, Perl TM, Saint S, Salgado CD, Weinstein RA, Wise R, Yokoe DS. Strategies to prevent ventilator-associated pneumonia in acute care hospitals. Infect Control Hosp Epidemiol 2009; 29 Suppl 1:S31-40. [PMID: 18840087 DOI: 10.1086/591062] [Citation(s) in RCA: 230] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections. The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their ventilator-associated pneumonia (VAP) prevention efforts. Refer to the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America “Compendium of Strategies to Prevent Healthcare-Associated Infections” Executive Summary and Introduction and accompanying editorial for additional discussion.1. Occurrence of VAP in acute care facilities.a. VAP is one of the most common infections acquired by adults and children in intensive care units (ICUs).i. In early studies, it was reported that 10%-20% of patients undergoing ventilation developed VAP. More-recent publications report rates of VAP that range from 1 to 4 cases per 1,000 ventilator-days, but rates may exceed 10 cases per 1,000 ventilator-days in some neonatal and surgical patient populations. The results of recent quality improvement initiatives, however, suggest that many cases of VAP might be prevented by careful attention to the process of care.2. Outcomes associated with VAPa. VAP is a cause of significant patient morbidity and mortality, increased utilization of healthcare resources, and excess cost.i. The mortality attributable to VAP may exceed 10%.ii. Patients with VAP require prolonged periods of mechanical ventilation, extended hospitalizations, excess use of antimicrobial medications, and increased direct medical costs.
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Affiliation(s)
- Susan E Coffin
- Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
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Dubberke ER, Gerding DN, Classen D, Arias KM, Podgorny K, Anderson DJ, Burstin H, Calfee DP, Coffin SE, Fraser V, Griffin FA, Gross P, Kaye KS, Klompas M, Lo E, Marschall J, Mermel LA, Nicolle L, Pegues DA, Perl TM, Saint S, Salgado CD, Weinstein RA, Wise R, Yokoe DS. Strategies to prevent clostridium difficile infections in acute care hospitals. Infect Control Hosp Epidemiol 2009; 29 Suppl 1:S81-92. [PMID: 18840091 DOI: 10.1086/591065] [Citation(s) in RCA: 153] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Erik R Dubberke
- Washington University School of Medicine, St. Louis, Missouri, USA
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Yokoe DS, Mermel LA, Anderson DJ, Arias KM, Burstin H, Calfee DP, Coffin SE, Dubberke ER, Fraser V, Gerding DN, Griffin FA, Gross P, Kaye KS, Klompas M, Lo E, Marschall J, Nicolle L, Pegues DA, Perl TM, Podgorny K, Saint S, Salgado CD, Weinstein RA, Wise R, Classen D. A compendium of strategies to prevent healthcare-associated infections in acute care hospitals. Infect Control Hosp Epidemiol 2009; 29 Suppl 1:S12-21. [PMID: 18840084 DOI: 10.1086/591060] [Citation(s) in RCA: 162] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Preventable healthcare-associated infections (HAIs) occur in US hospitals. Preventing these infections is a national priority, with initiatives led by healthcare organizations, professional associations, government and accrediting agencies, legislators, regulators, payers, and consumer advocacy groups. To assist acute care hospitals in focusing and prioritizing efforts to implement evidence-based practices for prevention of HAIs, the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America Standards and Practice Guidelines Committee appointed a task force to create a concise compendium of recommendations for the prevention of common HAIs. This compendium is implementation focused and differs from most previously published guidelines in that it highlights a set of basic HAI prevention strategies plus special approaches for use in locations and/or populations within the hospital when infections are not controlled by use of basic practices, recommends that accountability for implementing infection prevention practices be assigned to specific groups and individuals, and includes proposed performance measures for internal quality improvement efforts.
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Affiliation(s)
- Deborah S Yokoe
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Pegues DA. Rapid screening for methicillin-resistant Staphylococcus aureus (MRSA) did not reduce MRSA acquisition rate. ACP J Club 2008; 149:14. [PMID: 18710187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- David A Pegues
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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Russell DL, Flood A, Zaroda TE, Acosta C, Riley MMS, Busuttil RW, Pegues DA. Outcomes of colonization with MRSA and VRE among liver transplant candidates and recipients. Am J Transplant 2008; 8:1737-43. [PMID: 18557723 DOI: 10.1111/j.1600-6143.2008.02304.x] [Citation(s) in RCA: 107] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE) infections cause significant morbidity and mortality among liver transplant candidates and recipients. To assess rates of MRSA and VRE colonization, we obtained active surveillance cultures from 706 liver transplant candidates and recipients within 24 h of admission to an 11-bed liver transplant ICU from October 2000 to December 2005. Patients were followed prospectively to determine the cumulative risk of MRSA or VRE infection or death by colonization status. Outcomes were assessed by Kaplan-Meier survival analysis and Cox regression and multivariate logistic regression adjusting for covariates. The prevalence of newly detected MRSA nasal and VRE rectal colonization was 6.7% and 14.6%, respectively. Liver transplant candidates and recipients with MRSA colonization had an increased risk of MRSA infection (adjusted OR = 15.64, 95% CI 6.63-36.89) but not of death (adjusted OR = 1.00, 95% CI 0.43-2.30), whereas those with VRE colonization had an increased risk both of VRE infection (adjusted OR = 3.61, 95% CI 2.01-6.47) and of death (adjusted OR = 2.12, 95% CI 1.27-3.54) compared with noncolonized patients. Prevention and control strategies, including use of active surveillance cultures, should be implemented to reduce the rates of both MRSA and VRE colonization in this high-risk patient population.
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Affiliation(s)
- D L Russell
- Department of Hospital Epidemiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Pegues DA. Improving and enforcing compounding pharmacy practices to protect patients. Clin Infect Dis 2006; 43:838-40. [PMID: 16941363 DOI: 10.1086/507341] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2006] [Accepted: 06/23/2006] [Indexed: 11/03/2022] Open
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Winthrop KL, Kubak BM, Pegues DA, Hufana C, Costamagna P, Desmond E, Sanders C, Shen P, Flores-Ibarra L, Osborne E, Bruckner D, Flood J. Transmission of mycobacterium tuberculosis via lung transplantation. Am J Transplant 2004; 4:1529-33. [PMID: 15307842 DOI: 10.1111/j.1600-6143.2004.00536.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Organ donors are not routinely screened for tuberculosis (TB) in the United States. We investigated a case of pulmonary TB in a double-lung transplant recipient. We reviewed the donor's and recipient's records, and used molecular methods to compare the lung recipient's isolate with others from three sources: her hospital, the California state health department's genotyping database, and the donor's resident-nation of Guatemala. A respiratory specimen obtained from the lung recipient 1 day after transplantation grew Mycobacterium tuberculosis. Donor chest radiograph had a previously unnoticed pulmonary opacity that was present on post-transplant recipient chest radiographs and computed tomographs. The recipient's isolate was molecularly distinct from others at her hospital and in the state database, but was identical to two isolates from Guatemala. Tuberculosis was transmitted from lung donor to recipient. As organ transplantation becomes more common worldwide, similar cases could occur. Screening for TB in potential organ donors should be considered.
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Affiliation(s)
- Kevin L Winthrop
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, GA, USA.
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Hu G, Wang MJ, Miller MJ, Holland GN, Bruckner DA, Civen R, Bornstein LA, Mascola L, Lovett MA, Mondino BJ, Pegues DA. Ocular vaccinia following exposure to a smallpox vaccinee. Am J Ophthalmol 2004; 137:554-6. [PMID: 15013881 DOI: 10.1016/j.ajo.2003.09.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2003] [Indexed: 11/16/2022]
Abstract
PURPOSE To describe the presentation and management of the first identified case of ocular vaccinia infection associated with the current smallpox vaccination program. DESIGN Case report. METHODS Vaccinia virus was isolated by cell culture of a conjunctival swab. Direct staining with fluorescein isothiocyanate-labeled vaccinia antibody and polymerase chain reaction testing confirmed the diagnosis. RESULTS In February 2003, a 26-year-old woman developed right preseptal cellulitis and blepharoconjunctivitis following contact with a vaccinated member of the military. The preseptal cellulitis resolved with antibacterial therapy, and the conjunctival infection was treated successfully with a 14-day course of topical trifluridine and a single dose of intravenous vaccinia immune globulin. CONCLUSIONS To facilitate rapid diagnosis and appropriate treatment, clinicians must maintain a high index of suspicion for ocular smallpox vaccine-associated adverse reactions in vaccine recipients and their close contacts.
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Affiliation(s)
- Gang Hu
- Ocular Inflammatory Disease Center, Jules Stein Eye Institute and Department of Ophthalmology, Los Angeles, California 90095-1688, USA.
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Bearson BL, Labarca JA, Brankovic LE, Cohen M, Bruckner DA, Pegues DA. Use of quantitative antibiogram analysis to determine the clonality of coagulase-negative Staphylococcus species from blood culture. Clin Microbiol Infect 2004; 10:148-55. [PMID: 14759240 DOI: 10.1111/j.1469-0691.2004.00753.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Two phenotypic methods, quantitative antibiogram analysis and colony morphology, were compared to pulsed-field gel electrophoresis (PFGE) for distinguishing the clonality of coagulase-negative Staphylococcus (CNS) species. The results of these three methods were correlated with the patients' clinical findings for 23 episodes in which CNS species were isolated from two blood culture bottles within a 24-h period. Quantitative antibiogram and colony morphology at 24 h correlated with PFGE typing in 21 (91%) and 20 (87%) episodes, respectively. All episodes associated with CNS strains with identical PFGE patterns had quantitative antibiogram similarity coefficients < 10, whereas most episodes associated with strains with different PFGE patterns had quantitative antibiogram similarity coefficients >or= 17. The CNS isolate pairs were less likely to be associated with infection if the strains had different PFGE types or a quantitative antibiogram similarity coefficient >or= 17. Clinical microbiology laboratories should consider use of the quantitative antibiogram similarity coefficient to aid clinicians in distinguishing infection-associated CNS blood isolates from contaminants.
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Affiliation(s)
- B L Bearson
- Department of Pathology and Laboratory Medicine, UCLA Medical Center, University of California, Los Angeles, CA, USA.
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Pegues DA. Building better programs to prevent transmission of blood-borne pathogens to healthcare personnel: progress in the workplace, but still no end in sight. Infect Control Hosp Epidemiol 2003; 24:719-21. [PMID: 14587929 DOI: 10.1086/502118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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MESH Headings
- Diabetes Complications
- Diabetes Mellitus/surgery
- Graft Rejection
- Granuloma, Respiratory Tract/diagnostic imaging
- Granuloma, Respiratory Tract/pathology
- Humans
- Kidney Failure, Chronic/etiology
- Kidney Failure, Chronic/surgery
- Kidney Transplantation
- Lung/diagnostic imaging
- Lung/pathology
- Lung Diseases, Fungal/diagnostic imaging
- Lung Diseases, Fungal/pathology
- Male
- Meningitis, Cryptococcal/diagnostic imaging
- Meningitis, Cryptococcal/drug therapy
- Meningitis, Cryptococcal/pathology
- Middle Aged
- Pancreas Transplantation
- Tomography, X-Ray Computed
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Fairhurst RM, Kubak BM, Pegues DA, Moriguchi JD, Han KF, Haley JC, Kobashigawa JA. Mycobacterium haemophilum infections in heart transplant recipients: case report and review of the literature. Am J Transplant 2002; 2:476-9. [PMID: 12123216 DOI: 10.1034/j.1600-6143.2002.20514.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Non-tuberculous mycobacteria are becoming increasingly important pathogens among transplant recipients. We report a case of disseminated Mycobacterium haemophilum infection in a heart transplant recipient, manifesting as cellulitis, subcutaneous nodules, septic arthritis, and pneumonitis. Our case illustrates diverse challenges in the identification and treatment of this pathogen, such as its unique culture requirements and variable antimicrobial susceptibilities. Heightened clinical suspicion is necessary to establish a timely diagnosis so that optimal treatment can be administered.
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Affiliation(s)
- Rick M Fairhurst
- Division of Infectious Diseases, Department of Medicine, UCLA Medical Center, Los Angeles, CA 90095, USA
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Abstract
Non-tuberculous mycobacteria (NTM) have emerged as important pathogens in organ transplant recipients. Because NTM pulmonary infections vary in their clinical and radiographic presentations, heightened clinical suspicion is necessary for accurate diagnosis. We report a case of Mycobacterium abscessus empyema in a lung transplant recipient. Repeated attempts at identifying the organism from a variety of clinical specimens led to the correct diagnosis and treatment.
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Affiliation(s)
- Rick M Fairhurst
- Division of Infectious Diseases, Department of Medicine, UCLA Medical Center, Los Angeles, California 90095, USA
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Berger AD, Kubak BM, Shpiner RB, Levine MS, Pegues DA, Litwin MS. Transitional cell carcinoma of the bladder two years after successful lung transplantation: case report and review of the literature. Urology 2002. [DOI: 10.1016/s0090-4295(01)01519-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Pegues DA, Lasker BA, McNeil MM, Hamm PM, Lundal JL, Kubak BM. Cluster of cases of invasive aspergillosis in a transplant intensive care unit: evidence of person-to-person airborne transmission. Clin Infect Dis 2002; 34:412-6. [PMID: 11753826 DOI: 10.1086/338025] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2001] [Revised: 07/30/2001] [Indexed: 11/03/2022] Open
Abstract
In October 1998, a patient developed deep surgical-site and organ-space infection with Aspergillus fumigatus 11 days after undergoing liver retransplantation; subsequently, 2 additional patients in the transplant intensive care unit had invasive pulmonary infection with A. fumigatus diagnosed. It was determined that debriding and dressing wounds infected with Aspergillus species may result in aerosolization of spores and airborne person-to-person transmission.
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Affiliation(s)
- David A Pegues
- Division of Infectious Diseases, University of California Los Angeles Medical Center, Los Angeles, CA 90095-1688 , USA.
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Wong-Beringer A, Hindler J, Loeloff M, Queenan AM, Lee N, Pegues DA, Quinn JP, Bush K. Molecular correlation for the treatment outcomes in bloodstream infections caused by Escherichia coli and Klebsiella pneumoniae with reduced susceptibility to ceftazidime. Clin Infect Dis 2002; 34:135-46. [PMID: 11740699 DOI: 10.1086/324742] [Citation(s) in RCA: 105] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2001] [Revised: 07/24/2001] [Indexed: 11/04/2022] Open
Abstract
Data are limited on outcomes of treatment with extended-spectrum cephalosporins (ESCs) for infections caused by Enterobacteriaceae that produce extended-spectrum beta-lactamases (ESBLs). This study describes the largest treatment experience of a nonoutbreak series of bloodstream infections caused by strains of Escherichia coli (23 episodes) and Klebsiella pneumoniae (13 episodes) with a ceftazidime minimal inhibitory concentration of > or =2 microg/mL. E. coli isolates produced a greater variety of beta-lactamase types than did K. pneumoniae isolates, among which ESBL production was predominant. Five ESBL types were identified: TEM-12, TEM-71, TEM-6, SHV-12, and SHV-5. Most patients were treated empirically with an ESC-based regimen. A favorable response to treatment with a nonceftazidime ESC was observed when the causative pathogen produced either TEM-6 or TEM-12; ceftazidime treatment was associated with failure of therapy in all patients. Despite the limited clinical success, ESCs are currently not recommended for the treatment of serious infections caused by ESBL-producing strains.
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Affiliation(s)
- Annie Wong-Beringer
- Western University of Health Sciences, College of Pharmacy, Pomona, CA 91766, USA.
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