Do risk adjustment calculations used by governmental agencies adequately assess risk for infection after colon surgery?

BACKGROUND

Surgical site infections (SSIs) following colon surgery are associated with clinical and financial consequences. The Centers for Medicare and Medicaid Services (CMS) and the New York State Department of Health (NYSDOH) use risk adjustment variables to determine quality measure scores.

METHODS

Among patients in a large public system, surgical risk variables were compared between patients with and without SSIs. Propensity score matching, using CMS and NYSDOH risk variables, created control groups. Receiver Operating Characteristics (ROC) curves were created using current and augmented risk adjustment variables.

RESULTS

When matched using CMS risk variables, more patients with SSIs had contaminated/dirty wounds, longer duration of surgery, and emergency surgery. The addition of these variables significantly improved the CMS ROC curve. When matching NYSDOH variables, more SSI patients were male, had contaminated/dirty wounds, and tended to be younger. The addition of these variables to the current NYSDOH adjustment criteria did not significantly improve the ROC curve.

DISCUSSION

The CMS adjustment criteria for colon SSIs do not adequately account for complicated surgeries. The inclusion of additional variables significantly improved the performance of CMS risk adjustment.

CONCLUSIONS

Until more robust risk adjustment criteria are developed, the reporting of SSIs following colon surgery as a quality measure should be suspended.

Reduction in catheter-associated urinary tract infections following a diagnostic stewardship intervention

Catheter-associated urinary tract infections (CAUTIs) are a frequent hospital-acquired infection and public health concern. In an attempt to reduce the number of CAUTIs, an intervention that emphasized the appropriate laboratory evaluation by ordering providers was implemented. This intervention supplemented ongoing standard bundle protocols. Compared to the 16 months before the intervention, there was a significant decrease in the number of CAUTIs during the 12-month intervention period.

Impact of Prophylactic Antibiotic Selection on the Prevention and Bacterial Flora of Surgical Site Infections After Colorectal Surgery

Background: Deep incisional and organ/space surgical site infections (SSIs) after colorectal surgery are associated with adverse outcomes. Multiple antibiotic regimens are recommended for peri-operative prophylaxis, with no particular regimen preferred over another. We compared the prophylaxis regimens used in patients with and without SSIs, and the impact of regimens on the flora involved in SSIs. Patients and Methods: Information was extracted from the National Healthcare Safety Network databank of patients undergoing colorectal surgery from 2015 to 2022 in a large public healthcare system in New York City. Patients with SSIs were identified, and controlling for nine variables, propensity score matching was used to create a matched control group without SSIs. Prophylactic regimens were compared between the matched groups with and without SSIs. Also, for the patients with SSIs, the impact of the prophylactic regimen on the subsequent pathogens involved the infection was examined. Results: A total of 275 patients with SSIs were compared to a matched cohort without SSIs. The prophylactic regimens were extremely similar between the SSI and control groups. Among the patients who developed SSIs, more patients who received cefoxitin had emergence of select cephalosporin-resistant Enterobacterales and Bacteroides spp. when compared with those who received β-lactam-β-lactamase inhibitors. Conclusions: The distribution of surgical prophylaxis regimens was remarkably similar between patients developing serious SSIs and a closely matched cohort that did not develop an SSI. However, given the downstream effects of more resistant and anaerobic flora should an infection develop, use of cefoxitin should be re-evaluated as a prophylactic agent.

Carbapenem-Resistant Klebsiella pneumoniae in Large Public Acute-Care Healthcare System, New York, New York, USA, 2016-2022

Controlling the spread of carbapenem-resistant Enterobacterales is a global priority. Using National Healthcare Safety Network data, we characterized the changing epidemiology of carbapenem-resistant Klebsiella pneumoniae (CRKP) in a large public health system in New York, New York, USA. During 2016-2020, CRKP cases declined; however, during 2021-June 2022, a notable increase occurred. Of 509 cases, 262 (51%) were considered community-onset, including 149 in patients who were living at home. Of 182 isolates with proven or presumptive (ceftazidime/avibactam susceptible) enzymes, 143 were serine carbapenemases; most confirmed cases were K. pneumoniae carbapenemase. The remaining 39 cases were proven or presumptive metallo-β-lactamases; all confirmed cases were New Delhi metallo-β-lactamases. After 2020, a marked increase occurred in the percentage of isolates possessing metallo-β-lactamases. Most patients with metallo-β-lactamases originated from long-term care facilities. An aggressive and universal program involving surveillance and isolation will be needed to control the spread of CRKP in the city of New York.

Methicillin-resistant Staphylococcus aureus bacteremia during the coronavirus disease 2019 (COVID-19) pandemic: Trends and distinguishing characteristics among patients in a healthcare system in New York City

During the pandemic, the rate of healthcare facility-onset methicillin-resistant Staphylococcus aureus (MRSA) bacteremia was 5 times greater in patients admitted with coronavirus disease 2019 (COVID-19). The presence of central lines and mechanical ventilation likely contribute to this increased rate. The number of central-line-associated bacteremia cases may be underestimated in patients with COVID-19.

Trends in Clostridioides difficile infection across a public health hospital system in New York City 2019-2021: A cautionary note

Contrary to national reports, rates of healthcare facility-onset Clostridioides difficile infection across an 11-hospital system rose after the spring of 2020, when New York City was the epicenter for the COVID-19 pandemic. Antibiotic pressure from an escalation in cephalosporin usage correlated with this increase. The majority of cases of Clostridioides difficile were in patients without COVID-19, suggesting the pandemic has adversely impacted the healthcare of other inpatients.

The initial and lingering impact of coronavirus disease 2019 (COVID-19) on catheter-associated infections in a large healthcare system in New York City

Catheter-related infections increased during surges of coronavirus disease 2019 (COVID-19) in an 11-hospital system in New York City. A disproportionate number of central-line infections occurred in larger hospitals. Patients with COVID-19 had shorter times from catheter insertion to infection and a higher incidence of infections with enterococci.

Trends in Healthcare Facility-Onset Clostridioides difficile Infection and the Impact of Testing Schemes in an Acute Care Hospital System in New York City, 2016-2019

BACKGROUND

Healthcare facility-onset Clostridioides difficile infection is associated with adverse clinical outcomes and hospital reimbursement. A four-year review involving eleven hospitals of the NYC Health + Hospital system was undertaken.

METHODS

From 2016-2019, infection rates and standardized infection ratios (SIRs) were gathered from National Healthcare Safety Network. The C. difficile testing scheme at each facility was recorded.

RESULTS

For the eleven hospitals, declines in rates of C. difficile infection and SIRs were documented. However, this decline was driven by two hospitals that had high rates of infection in 2016; for the remaining nine hospitals, rates of infection and SIRs were at a plateau. Most hospitals used a testing scheme that fell into the nucleic acid amplification test (NAAT) category for SIR risk adjustment. Hospitals that used the algorithm glutamate dehydrogenase (GDH) and toxin A/B immunoassay (EIA) followed by NAAT for discrepant results had significantly lower rates of C. difficile infection but similar SIRs.

CONCLUSIONS

For most hospitals in this system, rates of C. difficile remained level. Within the NAAT test categories, SIRs may not correlate with infection rates. Given the controversies regarding testing and calculation of SIRs, alternatives to C. difficile infection should be sought as a hospital quality measurement.

A norovirus outbreak at a long-term-care facility: the role of environmental surface contamination

BACKGROUND

The role of environmental surface contamination in the propagation of norovirus outbreaks is unclear. An outbreak of acute gastroenteritis was reported among residents of a 240-bed veterans long-term-care facility.

OBJECTIVES

To identify the likely mode of transmission, to characterize risk factors for illness, and to evaluate for environmental contamination in this norovirus outbreak.

METHODS

An outbreak investigation was conducted to identify risk factors for illness among residents and employees. Stool and vomitus samples were tested for norovirus by reverse transcription polymerase chain reaction (RT-PCR). Fourteen days after outbreak detection, ongoing cases among the residents prompted environmental surface testing for norovirus by RT-PCR.

RESULTS

One hundred twenty-seven (52%) of 246 residents and 84 (46%) of 181 surveyed employees had gastroenteritis. Case-residents did not differ from non-case-residents by comorbidities, diet, room type, or level of mobility. Index cases were among the nursing staff. Eight of 11 resident stool or vomitus samples tested positive for genogroup II norovirus. The all-cause mortality rate during the month of the outbreak peak was significantly higher than the expected rate. Environmental surface swabs from case-resident rooms, a dining room table, and an elevator button used only by employees were positive for norovirus. Environmental and clinical norovirus sequences were identical.

CONCLUSION

Extensive contamination of environmental surfaces may play a role in prolonged norovirus outbreaks and should be addressed in control interventions.

Dermal ulcer cultures: frequency and associated symptoms

The identification of the colonized versus the infected dermal ulcer continues to be a major challenge for clinical practitioners. The purposes of this 3-month, prospective study were (1) to examine the current practice of culturing and use of antibiotics in treating dermal ulcers and (2) to examine associated symptoms of infected dermal ulcers in a 250-bed community hospital. A consecutive series design was used to obtain all patients (N = 63). The study revealed that 70% (44) of the patients dermal ulcers were not cultured. Additionally, symptoms normally associated with dermal ulcer infection, such as erythema, swelling, and abnormal drainage, were not always present in patients with infectious dermal ulcers.