1
|
Mani NS, Budak JZ, Lan KF, Bryson-Cahn C, Zelikoff A, Barker GEC, Grant CW, Hart K, Barbee CJ, Sandoval MD, Dostal CL, Corcorran M, Ungerleider HM, Gates JO, Olin SV, Bryan A, Hoffman NG, Marquis SR, Harvey ML, Nasenbeny K, Mertens K, Chew LD, Greninger AL, Jerome KR, Pottinger PS, Dellit TH, Liu C, Pergam SA, Neme S, Lynch JB, Kim HN, Cohen SA. Prevalence of Coronavirus Disease 2019 Infection and Outcomes Among Symptomatic Healthcare Workers in Seattle, Washington. Clin Infect Dis 2021; 71:2702-2707. [PMID: 32548613 PMCID: PMC7337651 DOI: 10.1093/cid/ciaa761] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [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: 05/13/2020] [Accepted: 06/11/2020] [Indexed: 02/07/2023] Open
Abstract
Background Healthcare workers (HCWs) who serve on the front lines of the coronavirus disease 2019 (COVID-19) pandemic have been at increased risk for infection due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in some settings. Healthcare-acquired infection has been reported in similar epidemics, but there are limited data on the prevalence of COVID-19 among HCWs and their associated clinical outcomes in the United States. Methods We established 2 high-throughput employee testing centers in Seattle, Washington, with drive-through and walk-through options for symptomatic employees in the University of Washington Medicine system and its affiliated organizations. Using data from these testing centers, we report the prevalence of SARS-CoV-2 infection among symptomatic employees and describe the clinical characteristics and outcomes among employees with COVID-19. Results Between 12 March 2020 and 23 April 2020, 3477 symptomatic employees were tested for COVID-19 at 2 employee testing centers; 185 (5.3%) employees tested positive for COVID-19. The prevalence of SARS-CoV-2 was similar when comparing frontline HCWs (5.2%) with nonfrontline staff (5.5%). Among 174 positive employees reached for follow-up at least 14 days after diagnosis, 6 reported COVID-related hospitalization; all recovered. Conclusions During the study period, we observed that the prevalence of positive SARS-CoV-2 tests among symptomatic HCWs was comparable to that of symptomatic nonfrontline staff. Reliable and rapid access to testing for employees is essential to preserve the health, safety, and availability of the healthcare workforce during this pandemic and to facilitate the rapid return of SARS-CoV-2–negative employees to work.
Collapse
Affiliation(s)
- Nandita S Mani
- Department of Medicine, School of Medicine, University of Washington, Seattle, Washington, USA
| | - Jehan Z Budak
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Kristine F Lan
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Chloe Bryson-Cahn
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Allison Zelikoff
- Population Health, Harborview Medical Center, Seattle, Washington, USA
| | - Gwendolyn E C Barker
- Allied Ambulatory Care Services, Harborview Medical Center, Seattle, Washington, USA
| | - Carolyn W Grant
- Patient Care Services, University of Washington Medical Center-Northwest, Seattle, Washington, USA
| | - Kristi Hart
- Patient Care Services, University of Washington Medical Center-Northwest, Seattle, Washington, USA
| | | | | | | | - Maria Corcorran
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Hal M Ungerleider
- Respiratory Therapy, University of Washington Medical Center-Northwest, Seattle, Washington, USA
| | - Jeff O Gates
- Employee Health, University of Washington Medical Center-Northwest, Seattle, Washington, USA
| | - Svaya V Olin
- Infection Prevention and Control, University of Washington Medical Center-Northwest, Seattle, Washington, USA
| | - Andrew Bryan
- Department of Laboratory Medicine, University of Washington Medical Center, Seattle, Washington, USA
| | - Noah G Hoffman
- Department of Laboratory Medicine, University of Washington Medical Center, Seattle, Washington, USA
| | - Sara R Marquis
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Michelle L Harvey
- Clinical Trials Office, University of Washington, Seattle, Washington, USA
| | - Keri Nasenbeny
- Patient Care Services, University of Washington Medical Center, Seattle, Washington, USA
| | - Kathleen Mertens
- Primary Care and Population Health, Harborview Medical Center, Seattle, Washington, USA
| | - Lisa D Chew
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Alexander L Greninger
- Department of Laboratory Medicine, University of Washington Medical Center, Seattle, Washington, USA.,Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Keith R Jerome
- Department of Laboratory Medicine, University of Washington Medical Center, Seattle, Washington, USA.,Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Paul S Pottinger
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Timothy H Dellit
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Catherine Liu
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA.,Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Steven A Pergam
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA.,Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Santiago Neme
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - John B Lynch
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - H Nina Kim
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA.,Allergy and Infectious Diseases/Department of Medicine Research Collaboratory, University of Washington, Seattle, Washington, USA
| | - Seth A Cohen
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| |
Collapse
|
2
|
Corcorran MA, Olin S, Rani G, Nasenbeny K, Constantino-Shor C, Holmes C, Quinnan-Hostein L, Solan W, Snoeyenbos Newman G, Roxby AC, Greninger AL, Jerome KR, Neme S, Lynch JB, Dellit TH, Cohen SA. Prolonged persistence of PCR-detectable virus during an outbreak of SARS-CoV-2 in an inpatient geriatric psychiatry unit in King County, Washington. Am J Infect Control 2021; 49:293-298. [PMID: 32827597 PMCID: PMC7438365 DOI: 10.1016/j.ajic.2020.08.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/13/2020] [Accepted: 08/14/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND We describe key characteristics, interventions, and outcomes of a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak within an inpatient geriatric psychiatry unit at the University of Washington Medical Center - Northwest. METHODS After identifying 2 patients with SARS-CoV-2 infection on March 11, 2020, we conducted an outbreak investigation and employed targeted interventions including: screening of patients and staff; isolation and cohorting of confirmed cases; serial testing; and enhanced infection prevention measures. RESULTS We identified 10 patients and 7 staff members with SARS-CoV-2 infection. Thirty percent of patients (n = 3) remained asymptomatic over the course of infection. Among SARS-CoV-2 positive patients, fever (n = 5, 50%) and cough (n = 4, 40%) were the most common symptoms. Median duration of reverse transcription polymerase chain reaction (RT-PCR) positivity was 25.5 days (interquartile range [IQR] 22.8-41.8) among symptomatic patients and 22.0 days (IQR 19.5-25.5) among asymptomatic patients. Median initial (19.0, IQR 18.7-25.7 vs 21.7, IQR 20.7-25.6) and nadir (18.9, IQR 18.2-20.3 vs 19.8, IQR 17.0-20.7) cycle threshold values were similar across symptomatic and asymptomatic patients, respectively. CONCLUSIONS Asymptomatic infection was common in this cohort of hospitalized, elderly individuals despite similar duration of SARS-CoV-2 RT-PCR positivity and cycle threshold values among symptomatic and asymptomatic patients.
Collapse
|
3
|
Bryson-Cahn C, Duchin J, Makarewicz VA, Kay M, Rietberg K, Napolitano N, Kamangu C, Dellit TH, Lynch JB. A Novel Approach for a Novel Pathogen: Using a Home Assessment Team to Evaluate Patients for COVID-19. Clin Infect Dis 2020; 71:2211-2214. [PMID: 32166310 PMCID: PMC7108172 DOI: 10.1093/cid/ciaa256] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 03/09/2020] [Indexed: 01/23/2023] Open
Abstract
Thousands of people in the United States have required testing for SARS-CoV-2. Evaluation for a special pathogen is resource intensive. We report an innovative approach to home assessment that, in collaboration with public health, enables safe evaluation and specimen collection outside the healthcare setting, avoiding unnecessary exposures and resource utilization.
Collapse
Affiliation(s)
- Chloe Bryson-Cahn
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA.,Infection Prevention and Control, Harborview Medical Center, Seattle, Washington, USA
| | - Jeffrey Duchin
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA.,Communicable Disease Epidemiology and Immunization, Prevention Division, Public Health-Seattle & King County, Seattle, Washington, USA
| | - Vanessa A Makarewicz
- Infection Prevention and Control, Harborview Medical Center, Seattle, Washington, USA
| | - Meagan Kay
- Communicable Disease Epidemiology and Immunization, Prevention Division, Public Health-Seattle & King County, Seattle, Washington, USA
| | - Krista Rietberg
- Infection Prevention and Control, Harborview Medical Center, Seattle, Washington, USA
| | - Nathanael Napolitano
- Infection Prevention and Control, Harborview Medical Center, Seattle, Washington, USA
| | - Carole Kamangu
- Infection Prevention and Control, Harborview Medical Center, Seattle, Washington, USA
| | - Timothy H Dellit
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - John B Lynch
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA.,Infection Prevention and Control, Harborview Medical Center, Seattle, Washington, USA
| |
Collapse
|
4
|
Kim CS, Meo N, Little D, Morris SC, Brandenburg LA, Moratti M, Dold CL, Staiger TO, Sayre C, Goss JR, Dayao JM, Dellit TH. Bracing for the Storm: One Health Care System's Planning for the COVID-19 Surge. Jt Comm J Qual Patient Saf 2020; 47:S1553-7250(20)30243-9. [PMID: 33069619 PMCID: PMC7546945 DOI: 10.1016/j.jcjq.2020.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 09/17/2020] [Accepted: 09/18/2020] [Indexed: 11/21/2022]
Abstract
PROBLEM University of Washington Medicine (UW Medicine), an academic health system in Washington State, was at the epicenter of the first outbreak of the COVID-19 pandemic in the United States. The extent of emergency activation needed to adequately respond to this global pandemic was not immediately known, as the evolving situation differed significantly from any past disaster response preparations in that there was potential for exponential growth of infection, unproven mitigation strategies, serious risk to health care workers, and inadequate supply chains for critical equipment. APPROACH The rapid transition of the UW Medicine system to account for projected COVID-19 and usual patient care, while balancing patient and staff safety and conservation of resources, represents an example of an adaptive disaster response. KEY INSIGHTS Although our organization's ability to meet the needs of the public was uncertain, we planned and implemented changes to space, supply management, and staffing plans to meet the influx of patients across our clinical entities. The surge management plan called for specific actions to be implemented based on the level of activity. This article describes the approach taken by UW Medicine as we braced for the storm.
Collapse
|
5
|
Kim CS, Lynch JB, Cohen S, Neme S, Staiger TO, Evans L, Pergam SA, Liu C, Bryson-Cahn C, Dellit TH. One Academic Health System's Early (and Ongoing) Experience Responding to COVID-19: Recommendations From the Initial Epicenter of the Pandemic in the United States. Acad Med 2020; 95:1146-1148. [PMID: 32282371 PMCID: PMC7176258 DOI: 10.1097/acm.0000000000003410] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
On January 19, 2020, the first case of a patient with coronavirus disease 2019 (COVID-19) in the United States was reported in Washington State. On February 29, 2020, a patient infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) passed away in a hospital in Seattle-King County, the first reported COVID-19-related death in the United States. That same day, a skilled nursing and rehabilitation facility in the county reported that several of its residents tested positive for SARS-CoV-2 and that many staff had symptoms compatible with COVID-19.The University of Washington Medicine health system (UW Medicine), which is based in Seattle-King County and provides quaternary care for the region, was one of several health care organizations called upon to address this growing crisis. What ensued was a series of swiftly enacted decisions and activities at UW Medicine, in partnership with local, state, and national public health agencies, to respond to the COVID-19 pandemic. Tapping into the multipronged mission areas of academic medicine, UW Medicine worked to support the community, innovate in science and clinical practice; lead policy and practice guideline development; and adopt changes as the crisis unfolded. In doing so, health system leaders had to balance their commitments to students, residents and fellows, researchers, faculty, staff, and hospital and health center entities, while ensuring that patients continued to receive cutting-edge, high-quality, safe care. In this Invited Commentary, the authors highlight the work and challenges UW Medicine has faced in responding to the global COVID-19 pandemic.
Collapse
Affiliation(s)
- Christopher S. Kim
- C.S. Kim is associate medical director, Quality, Patient Safety, and Clinical Efficiency, University of Washington Medical Center, and associate professor, Division of General Internal Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - John B. Lynch
- J.B. Lynch is medical director, Infection Prevention and Control, Harborview Medical Center, and associate professor, Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Seth Cohen
- J.B. Lynch is medical director, Infection Prevention and Control, Harborview Medical Center, and associate professor, Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Santiago Neme
- S. Cohen is medical director, Infection Prevention and Employee Health, University of Washington Medical Center, and clinical assistant professor, Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Thomas O. Staiger
- S. Neme is medical director, University of Washington Medical Center, Northwest Campus, and clinical assistant professor, Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Laura Evans
- T.O. Staiger is medical director, University of Washington Medical Center, and professor, Division of General Internal Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Steven A. Pergam
- L. Evans is associate medical director, Critical Care, University of Washington Medical Center, and associate professor, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Catherine Liu
- S.A. Pergam is medical director, Infection Prevention, Seattle Cancer Care Alliance, and associate professor, Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Chloe Bryson-Cahn
- C. Liu is medical director, Antimicrobial Stewardship, Seattle Cancer Care Alliance, and associate professor, Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Timothy H. Dellit
- C. Bryson-Cahn is associate medical director, Infection Prevention and Control, Harborview Medical Center, and assistant professor, Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| |
Collapse
|
6
|
Roxby AC, Greninger AL, Hatfield KM, Lynch JB, Dellit TH, James A, Taylor J, Page LC, Kimball A, Arons M, Munanga A, Stone N, Jernigan JA, Reddy SC, Lewis J, Cohen SA, Jerome KR, Duchin JS, Neme S. Outbreak Investigation of COVID-19 Among Residents and Staff of an Independent and Assisted Living Community for Older Adults in Seattle, Washington. JAMA Intern Med 2020; 180:1101-1105. [PMID: 32437547 PMCID: PMC7292007 DOI: 10.1001/jamainternmed.2020.2233] [Citation(s) in RCA: 82] [Impact Index Per Article: 20.5] [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: 12/14/2022]
Abstract
IMPORTANCE Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused epidemic spread of coronavirus disease 2019 (COVID-19) in the Seattle, Washington, metropolitan area, with morbidity and mortality concentrated among residents of skilled nursing facilities. The prevalence of COVID-19 among older adults in independent/assisted living is not understood. OBJECTIVES To conduct surveillance for SARS-CoV-2 and describe symptoms of COVID-19 among residents and staff of an independent/assisted living community. DESIGN, SETTING, AND PARTICIPANTS In March 2020, public health surveillance of staff and residents was conducted on site at an assisted and independent living residence for older adults in Seattle, Washington, after exposure to 2 residents who were hospitalized with COVID-19. EXPOSURES Surveillance for SARS-CoV-2 infection in a congregate setting implementing social isolation and infection prevention protocols. MAIN OUTCOMES AND MEASURES SARS-CoV-2 real-time polymerase chain reaction was performed on nasopharyngeal swabs from residents and staff; a symptom questionnaire was completed assessing fever, cough, and other symptoms for the preceding 14 days. Residents were retested for SARS-CoV-2 7 days after initial screening. RESULTS Testing was performed on 80 residents; 62 were women (77%), with mean age of 86 (range, 69-102) years. SARS-CoV-2 was detected in 3 of 80 residents (3.8%); none felt ill, 1 male resident reported resolved cough and 1 loose stool during the preceding 14 days. Virus was also detected in 2 of 62 staff (3.2%); both were symptomatic. One week later, resident SARS-CoV-2 testing was repeated and 1 new infection detected (asymptomatic). All residents remained in isolation and were clinically stable 14 days after the second test. CONCLUSIONS AND RELEVANCE Detection of SARS-CoV-2 in asymptomatic residents highlights challenges in protecting older adults living in congregate settings. In this study, symptom screening failed to identify residents with infections and all 4 residents with SARS-CoV-2 remained asymptomatic after 14 days. Although 1 asymptomatic infection was found on retesting, a widespread facility outbreak was avoided. Compared with skilled nursing settings, in assisted/independent living communities, early surveillance to identify asymptomatic persons among residents and staff, in combination with adherence to recommended preventive strategies, may reduce viral spread.
Collapse
Affiliation(s)
- Alison C Roxby
- Department of Medicine, University of Washington, Seattle.,Department of Global Health, University of Washington, Seattle
| | | | | | - John B Lynch
- Department of Medicine, University of Washington, Seattle
| | | | - Allison James
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Joanne Taylor
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Anne Kimball
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Melissa Arons
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Albert Munanga
- School of Nursing, Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle.,Era Living Retirement Communities, Seattle, Washington
| | - Nimalie Stone
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - John A Jernigan
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sujan C Reddy
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - James Lewis
- Public Health Seattle, King County, Washington
| | - Seth A Cohen
- Department of Medicine, University of Washington, Seattle
| | - Keith R Jerome
- Department of Laboratory Medicine, University of Washington, Seattle.,Fred Hutchinson Cancer Research Center, Vaccine and Infectious Disease Division, Seattle, Washington
| | - Jeffrey S Duchin
- Department of Medicine, University of Washington, Seattle.,Public Health Seattle, King County, Washington
| | - Santiago Neme
- Department of Medicine, University of Washington, Seattle
| |
Collapse
|
7
|
Roxby AC, Greninger AL, Hatfield KM, Lynch JB, Dellit TH, James A, Taylor J, Page LC, Kimball A, Arons M, Schieve LA, Munanga A, Stone N, Jernigan JA, Reddy SC, Lewis J, Cohen SA, Jerome KR, Duchin JS, Neme S. Detection of SARS-CoV-2 Among Residents and Staff Members of an Independent and Assisted Living Community for Older Adults - Seattle, Washington, 2020. MMWR Morb Mortal Wkly Rep 2020; 69:416-418. [PMID: 32271726 PMCID: PMC7147909 DOI: 10.15585/mmwr.mm6914e2] [Citation(s) in RCA: 88] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
|
8
|
Durvasula R, Kelly J, Schleyer A, Anawalt BD, Somani S, Dellit TH. Standardized Review and Approval Process for High-Cost Medication Use Promotes Value-Based Care in a Large Academic Medical System. Am Health Drug Benefits 2018; 11:65-73. [PMID: 29915640 PMCID: PMC5973244] [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] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 10/14/2017] [Indexed: 06/08/2023]
Abstract
BACKGROUND As healthcare costs rise and reimbursements decrease, healthcare organization leadership and clinical providers must collaborate to provide high-value healthcare. Medications are a key driver of the increasing cost of healthcare, largely as a result of the proliferation of expensive specialty drugs, including biologic agents. Such medications contribute significantly to the inpatient diagnosis-related group payment system, often with minimal or unproved benefit over less-expensive therapies. OBJECTIVE To describe a systematic review process to reduce non-evidence-based inpatient use of high-cost medications across a large multihospital academic health system. METHODS We created a Pharmacy & Therapeutics subcommittee consisting of clinicians, pharmacists, and an ethics representative. This committee developed a standardized process for a timely review (<48 hours) and approval of high-cost medications based on their clinical effectiveness, safety, and appropriateness. The engagement of clinical experts in the development of the consensus-based guidelines for the use of specific medications facilitated the clinicians' acceptance of the review process. RESULTS Over a 2-year period, a total of 85 patient-specific requests underwent formal review. All reviews were conducted within 48 hours. This review process has reduced the non-evidence-based use of specialty medications and has resulted in a pharmacy savings of $491,000 in fiscal year 2016, with almost 80% of the savings occurring in the last 2 quarters, because our process has matured. CONCLUSION The creation of a collaborative review process to ensure consistent, evidence-based utilization of high-cost medications provides value-based care, while minimizing unnecessary practice variation and reducing the cost of inpatient care.
Collapse
Affiliation(s)
- Raghu Durvasula
- Associate Professor of Medicine, Division of Nephrology, University of Washington Medical Center, Seattle
| | - Janet Kelly
- Assistant Director of Pharmacy Services, University of Washington Medical Center
| | - Anneliese Schleyer
- Associate Professor of Medicine, Harborview Medical Center, University of Washington
| | - Bradley D Anawalt
- Professor of Medicine, Division of General Internal Medicine, Department of Medicine, University of Washington
| | - Shabir Somani
- Chief Pharmacy Officer and Assistant Dean, University of Washington School of Pharmacy
| | - Timothy H Dellit
- Professor of Medicine, Harborview Medical Center, University of Washington School of Medicine
| |
Collapse
|
9
|
Barlam TF, Cosgrove SE, Abbo LM, MacDougall C, Schuetz AN, Septimus EJ, Srinivasan A, Dellit TH, Falck-Ytter YT, Fishman NO, Hamilton CW, Jenkins TC, Lipsett PA, Malani PN, May LS, Moran GJ, Neuhauser MM, Newland JG, Ohl CA, Samore MH, Seo SK, Trivedi KK. Executive Summary: Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis 2017; 62:1197-1202. [PMID: 27118828 DOI: 10.1093/cid/ciw217] [Citation(s) in RCA: 256] [Impact Index Per Article: 36.6] [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: 02/22/2016] [Accepted: 02/23/2016] [Indexed: 11/14/2022] Open
Abstract
Evidence-based guidelines for implementation and measurement of antibiotic stewardship interventions in inpatient populations including long-term care were prepared by a multidisciplinary expert panel of the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. The panel included clinicians and investigators representing internal medicine, emergency medicine, microbiology, critical care, surgery, epidemiology, pharmacy, and adult and pediatric infectious diseases specialties. These recommendations address the best approaches for antibiotic stewardship programs to influence the optimal use of antibiotics.
Collapse
Affiliation(s)
- Tamar F Barlam
- Section of Infectious Diseases, Boston University School of Medicine, Boston, Massachusetts
| | - Sara E Cosgrove
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lilian M Abbo
- Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida
| | - Conan MacDougall
- Department of Clinical Pharmacy, School of Pharmacy, University of California, San Francisco
| | - Audrey N Schuetz
- Department of Medicine, Weill Cornell Medical Center/New York-Presbyterian Hospital, New York, New York
| | - Edward J Septimus
- Department of Internal Medicine, Texas A&M Health Science Center College of Medicine, Houston
| | - Arjun Srinivasan
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Timothy H Dellit
- Division of Allergy and Infectious Diseases, University of Washington School of Medicine, Seattle
| | - Yngve T Falck-Ytter
- Department of Medicine, Case Western Reserve University and Veterans Affairs Medical Center, Cleveland, Ohio
| | - Neil O Fishman
- Department of Medicine, University of Pennsylvania Health System, Philadelphia
| | | | | | - Pamela A Lipsett
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University Schools of Medicine and Nursing, Baltimore, Maryland
| | - Preeti N Malani
- Division of Infectious Diseases, University of Michigan Health System, Ann Arbor
| | - Larissa S May
- Department of Emergency Medicine, University of California, Davis
| | - Gregory J Moran
- Department of Emergency Medicine, David Geffen School of Medicine, University of California, Los Angeles Medical Center, Sylmar
| | | | - Jason G Newland
- Department of Pediatrics, Washington University School of Medicine in St. Louis, Missouri
| | - Christopher A Ohl
- Section on Infectious Diseases, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Matthew H Samore
- Department of Veterans Affairs and University of Utah, Salt Lake City
| | - Susan K Seo
- Infectious Diseases, Memorial Sloan Kettering Cancer Center, New York, New York
| | | |
Collapse
|
10
|
Hippe DS, Lehnert BE, Slade IR, Dellit TH, Hough CL, Schreuder AB, Cohen W, Miklusis JA, Pergamit R, Roma H, Potter AC, Bresnahan BW. Reducing Portable Chest Radiography in the Intensive Care Unit. J Am Coll Radiol 2017; 14:1363-1368. [PMID: 28697958 DOI: 10.1016/j.jacr.2017.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 05/31/2017] [Accepted: 06/05/2017] [Indexed: 11/17/2022]
Affiliation(s)
- Daniel S Hippe
- Department of Radiology, University of Washington, Seattle, Washington
| | - Bruce E Lehnert
- Department of Radiology, University of Washington, Seattle, Washington
| | - Ian R Slade
- Department of Anesthesiology, University of Washington, Seattle, Washington
| | - Timothy H Dellit
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington
| | - Catherine L Hough
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington
| | - Astrid B Schreuder
- Quality Improvement Department, Harborview Medical Center, Seattle, Washington
| | - Wendy Cohen
- Department of Radiology, University of Washington, Seattle, Washington
| | - James A Miklusis
- UW Medicine Finance, University of Washington, Seattle, Washington
| | - Ronald Pergamit
- Quality Improvement Department, Harborview Medical Center, Seattle, Washington
| | - Herb Roma
- Department of Radiology, University of Washington, Seattle, Washington
| | - Amanda C Potter
- Quality Improvement Department, Harborview Medical Center, Seattle, Washington
| | - Brian W Bresnahan
- Department of Radiology, University of Washington, Seattle, Washington.
| |
Collapse
|
11
|
Chan JD, Dellit TH, Lynch JB. Hospital Length of Stay Among Patients Receiving Intermittent Versus Prolonged Piperacillin/Tazobactam Infusion in the Intensive Care Units. J Intensive Care Med 2017; 33:134-141. [PMID: 28486867 DOI: 10.1177/0885066617708756] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES We sought to evaluate clinical outcomes of intensive care unit (ICU) patients following a hospital-wide initiative of prolonged piperacillin/tazobactam (PIP/TAZ) infusion. METHODS Retrospective observational study of patients >18 years old who was hospitalized in the ICU receiving PIP/TAZ for >72 hours during the preimplementation (June 1, 2010 to May 31, 2011) and postimplementation (July 7, 2011 to June 30, 2014) periods. RESULTS There were 124 and 429 patients who met inclusion criteria with average age of 54.3 and 56.9 years, and average duration of PIP/TAZ therapy was 6.1 ± 2.8 days and 5.9 ± 3.4 days in the pre- and postimplementation period, respectively. Intensive care unit and hospital length of stay (LOS) following initiation of PIP/TAZ were 8.0 ± 8.4 days versus 6.4 ± 6.8 days and 26.3 ± 22.8 days versus 20.4 ± 16.1 days among patients in the pre- and postimplementation periods, respectively. Compared to patients who received intermittent PIP/TAZ infusion, the adjusted difference in ICU and hospital LOS was 0.6 ± 0.8 days (95% confidence interval [CI]: -0.9 to 2.1 days) and 5.6 ± 2.1 days (95% CI: 1.4 - 9.7 days) shorter among patients who received prolonged PIP/TAZ infusion. At hospital discharge, 19 (15.3%) intermittent infusion and 74 (17.2%) prolonged infusion recipients had died. In comparison to intermittent infusion recipients, the adjusted odds ratio for mortality was 1.17 (95% CI: 0.65-2.1) with prolonged infusion. CONCLUSION Our study demonstrated a reduction in hospital LOS with prolonged PIP/TAZ infusion among critically ill patients. Randomized trials are needed to further validate these findings.
Collapse
Affiliation(s)
- Jeannie D Chan
- 1 Department of Pharmacy, Harborview Medical Center, School of Pharmacy, University of Washington, Seattle, WA, USA.,2 Division of Allergy and Infectious Diseases, Department of Medicine, Harborview Medical Center and School of Medicine, University of Washington, Seattle, WA, USA
| | - Timothy H Dellit
- 2 Division of Allergy and Infectious Diseases, Department of Medicine, Harborview Medical Center and School of Medicine, University of Washington, Seattle, WA, USA
| | - John B Lynch
- 2 Division of Allergy and Infectious Diseases, Department of Medicine, Harborview Medical Center and School of Medicine, University of Washington, Seattle, WA, USA
| |
Collapse
|
12
|
Zelikoff AJ, Dellit TH, Lynch J, McNamara EA, Makarewicz VA. Cleaning practices in the hospital setting: Are high-touch surfaces in isolation and standard precaution patient rooms cleaned to the same standard? Am J Infect Control 2016; 44:1399-1400. [PMID: 27317406 DOI: 10.1016/j.ajic.2016.04.220] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 04/25/2016] [Accepted: 04/25/2016] [Indexed: 11/29/2022]
Abstract
The purpose of this quality improvement project was to identify differences in cleaning practices between isolation rooms and standard precaution rooms in the hospital setting. An ultravoilet marking system was used to evaluate high-touch surfaces throughout the patient environment. Results reveal the importance of refining training systems to reflect staff perceptions and improve evaluation processes across systems in an effort to reduce health care-associated infections.
Collapse
Affiliation(s)
| | - Timothy H Dellit
- Infection Prevention & Control, Harborview Medical Center, Seattle, WA
| | - John Lynch
- Infection Prevention & Control, Harborview Medical Center, Seattle, WA
| | | | | |
Collapse
|
13
|
Morton RP, Abecassis IJ, Hanson JF, Barber J, Nerva JD, Emerson SN, Ene CI, Chowdhary MM, Levitt MR, Ko AL, Dellit TH, Chesnut RM. Predictors of infection after 754 cranioplasty operations and the value of intraoperative cultures for cryopreserved bone flaps. J Neurosurg 2016; 125:766-70. [DOI: 10.3171/2015.8.jns151390] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
The authors' aim was to report the largest study on predictors of infection after cranioplasty and to assess the predictive value of intraoperative bone flap cultures before cryopreservation.
METHODS
They retrospectively examined all cranioplasties performed between March 2004 and November 2014. Throughout this study period, the standard protocol during initial craniectomy was to obtain a culture swab of the extracted autologous bone flap (ABF)—prior to its placement in cytostorage—to screen for microbial contamination. Two consecutive protocols were employed for the use and interpretation of the intraoperative swab culture results: A) From March 2004 through June 2013, any culture-positive ABF (+ABF) was discarded and a custom synthetic prosthesis was implanted at the time of cranioplasty. B) From July 2013 through November 2014, any ABF with a skin flora organism was not discarded. Instead, cryopreservation was maintained and the +ABF was reimplanted after a 10-minute soak in bacitracin irrigation as well as a 3-minute soak in betadine.
RESULTS
Over the 10.75-year period, 754 cranioplasty procedures were performed. The median time from craniectomy to cranioplasty was 123 days. Median follow-up after cranioplasty was 237 days for protocol A and 225 days for protocol B. The overall infection rate after cranioplasty was 6.6% (50 cases) occurring at a median postoperative Day 31. Staphylococcus spp. were involved as the causative organisms in 60% of cases.
Culture swabs taken at the time of initial craniectomy were available for 640 ABFs as 114 ABFs were not salvageable. One hundred twenty-six (20%) were culture positive. Eighty-nine +ABFs occurred during protocol A and were discarded in favor of a synthetic prosthesis at the time of cranioplasty, whereas 37 +ABFs occurred under protocol B and were reimplanted at the time of cranioplasty.
Cranioplasty material did not affect the postcranioplasty infection rate. There was no significant difference in the infection rate among sterile ABFs (7%), +ABFs (8%), and synthetic prostheses (5.5%; p = 0.425). All 3 +ABF infections under protocol B were caused by organisms that differed from those in the original intraoperative bone culture from the initial craniectomy. A cranioplasty procedure ≤ 14 days after initial craniectomy was the only significant predictor of postcranioplasty infection (p = 0.007, HR 3.62).
CONCLUSIONS
Cranioplasty procedures should be performed at least 14 days after initial craniectomy to minimize infection risk. Obtaining intraoperative bone cultures at the time of craniectomy in the absence of clinical infection should be discontinued as the culture results were not a useful predictor of postcranioplasty infection and led to the unnecessary use of synthetic prostheses and increased health care costs.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Timothy H. Dellit
- 2Infection Control, Harborview Medical Center, University of Washington School of Medicine, Seattle, Washington
| | | |
Collapse
|
14
|
Beieler AM, Dellit TH, Chan JD, Dhanireddy S, Enzian LK, Stone TJ, Dwyer-O'Connor E, Lynch JB. Successful implementation of outpatient parenteral antimicrobial therapy at a medical respite facility for homeless patients. J Hosp Med 2016; 11:531-5. [PMID: 27120700 DOI: 10.1002/jhm.2597] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 03/14/2016] [Accepted: 03/31/2016] [Indexed: 11/10/2022]
Abstract
BACKGROUND Outpatient parenteral antimicrobial therapy (OPAT) is a safe way to administer intravenous (IV) antimicrobial therapy to patients with the potential to decrease hospital length of stay (LOS). Often, homeless patients with complex infections, who could otherwise be treated as an outpatient, remain in the hospital for the duration of IV antibiotic treatment. Injection drug use (IDU) is a barrier to OPAT. OBJECTIVE To evaluate our experience with administering OPAT to homeless patients at a medical respite facility and determine if patients could complete a successful course of antibiotics. DESIGN Using retrospective chart review, demographics, diagnosis, and comorbidities including mental illness, current IDU, and remote IDU (>3 months ago) were recorded. Surgical, microbiologic, and antimicrobial therapy including route (IV or oral), duration of therapy, and adverse events were abstracted. PARTICIPANTS Homeless patients >18 years old who received OPAT at medical respite after discharge, no exclusions. MAIN MEASUREMENTS Primary outcome was successful completion of OPAT at medical respite. Secondary outcome was successful antimicrobial course completion for a specific diagnosis. RESULTS Forty-six (87%) patients successfully completed a defined course of antibiotic therapy. Thirty-four (64%) patients were successfully treated with OPAT at medical respite. Readmission rate was 30%. The average length of OPAT was 22 days. The cost savings to our institution (using $1500/day inpatient cost) was $25,000 per episode of OPAT. CONCLUSIONS OPAT can be successful in a supervised medical respite setting for homeless patients with the help of a multidisciplinary team, and can decrease inpatient LOS resulting in cost savings. Journal of Hospital Medicine 2016;11:531-535. © 2016 Society of Hospital Medicine.
Collapse
Affiliation(s)
- Alison M Beieler
- Infectious Diseases, Harborview Medical Center, Seattle, Washington
| | - Timothy H Dellit
- Infectious Diseases, Harborview Medical Center, Seattle, Washington
- Department of Allergy and Infectious Diseases, University of Washington, Seattle, Washington
| | - Jeannie D Chan
- Infectious Diseases, Harborview Medical Center, Seattle, Washington
- Department of Pharmacy, University of Washington, Seattle, Washington
| | - Shireesha Dhanireddy
- Infectious Diseases, Harborview Medical Center, Seattle, Washington
- Department of Allergy and Infectious Diseases, University of Washington, Seattle, Washington
| | - Leslie K Enzian
- Edward Thomas House Medical Respite at Jefferson Terrace, Harborview Medical Center, Seattle, Washington
| | - Tamera J Stone
- Edward Thomas House Medical Respite at Jefferson Terrace, Harborview Medical Center, Seattle, Washington
| | - Edward Dwyer-O'Connor
- Edward Thomas House Medical Respite at Jefferson Terrace, Harborview Medical Center, Seattle, Washington
| | - John B Lynch
- Infectious Diseases, Harborview Medical Center, Seattle, Washington
- Department of Allergy and Infectious Diseases, University of Washington, Seattle, Washington
| |
Collapse
|
15
|
Barlam TF, Cosgrove SE, Abbo LM, MacDougall C, Schuetz AN, Septimus EJ, Srinivasan A, Dellit TH, Falck-Ytter YT, Fishman NO, Hamilton CW, Jenkins TC, Lipsett PA, Malani PN, May LS, Moran GJ, Neuhauser MM, Newland JG, Ohl CA, Samore MH, Seo SK, Trivedi KK. Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis 2016; 62:e51-77. [PMID: 27080992 PMCID: PMC5006285 DOI: 10.1093/cid/ciw118] [Citation(s) in RCA: 1769] [Impact Index Per Article: 221.1] [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] [Received: 02/22/2016] [Accepted: 02/23/2016] [Indexed: 12/11/2022] Open
Abstract
Evidence-based guidelines for implementation and measurement of antibiotic stewardship interventions in inpatient populations including long-term care were prepared by a multidisciplinary expert panel of the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. The panel included clinicians and investigators representing internal medicine, emergency medicine, microbiology, critical care, surgery, epidemiology, pharmacy, and adult and pediatric infectious diseases specialties. These recommendations address the best approaches for antibiotic stewardship programs to influence the optimal use of antibiotics.
Collapse
Affiliation(s)
- Tamar F Barlam
- Section of Infectious Diseases, Boston University School of Medicine, Boston, Massachusetts
| | - Sara E Cosgrove
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lilian M Abbo
- Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida
| | - Conan MacDougall
- Department of Clinical Pharmacy, School of Pharmacy, University of California, San Francisco
| | - Audrey N Schuetz
- Department of Medicine, Weill Cornell Medical Center/New York-Presbyterian Hospital, New York, New York
| | - Edward J Septimus
- Department of Internal Medicine, Texas A&M Health Science Center College of Medicine, Houston
| | - Arjun Srinivasan
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Timothy H Dellit
- Division of Allergy and Infectious Diseases, University of Washington School of Medicine, Seattle
| | - Yngve T Falck-Ytter
- Department of Medicine, Case Western Reserve University and Veterans Affairs Medical Center, Cleveland, Ohio
| | - Neil O Fishman
- Department of Medicine, University of Pennsylvania Health System, Philadelphia
| | | | | | - Pamela A Lipsett
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University Schools of Medicine and Nursing, Baltimore, Maryland
| | - Preeti N Malani
- Division of Infectious Diseases, University of Michigan Health System, Ann Arbor
| | - Larissa S May
- Department of Emergency Medicine, University of California, Davis
| | - Gregory J Moran
- Department of Emergency Medicine, David Geffen School of Medicine, University of California, Los Angeles Medical Center, Sylmar
| | | | - Jason G Newland
- Department of Pediatrics, Washington University School of Medicine in St. Louis, Missouri
| | - Christopher A Ohl
- Section on Infectious Diseases, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Matthew H Samore
- Department of Veterans Affairs and University of Utah, Salt Lake City
| | - Susan K Seo
- Infectious Diseases, Memorial Sloan Kettering Cancer Center, New York, New York
| | | |
Collapse
|
16
|
Dellit TH, Chan JD, Fulton C, Pergamit RF, McNamara EA, Kim LJ, Ellenbogen RG, Lynch JB. Reduction in Clostridium difficile Infections among Neurosurgical Patients Associated with Discontinuation of Antimicrobial Prophylaxis for the Duration of External Ventricular Drain Placement. Infect Control Hosp Epidemiol 2016; 35:589-90. [DOI: 10.1086/675828] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
|
17
|
Tulloch LG, Chan JD, Carlbom DJ, Kelly MJ, Dellit TH, Lynch JB. Epidemiology and Microbiology of Sepsis Syndromes in a University-Affiliated Urban Teaching Hospital and Level-1 Trauma and Burn Center. J Intensive Care Med 2015; 32:264-272. [PMID: 26130580 DOI: 10.1177/0885066615592851] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
PURPOSE To use the 2010 to 2011 data collected by structured chart review to provide a detailed up-to-date description of the epidemiology and microbiology of the sepsis syndromes. METHODS Prospective observational study conducted at a university-affiliated urban teaching hospital and level-1 trauma and burn center. All adult patients who triggered a Code Sepsis in the emergency department (ED) between January 2010 and December 2011 were included. RESULTS One hundred eighty four patients presented with a verified sepsis syndrome and triggered a Code Sepsis in the ED during the studied time period. The mean hospital and intensive care unit length of stays (LOSs) were 15.4 (interquartile range [IQR] = 14) and 6.7 (IQR = 5) days, respectively. The total inpatient mortality was 19% (n = 35). Patients with an unspecified source of infection and those without an isolated pathogen had the highest inpatient mortality, 42.1% (n = 8) and 23.3% (n = 10), respectively. CONCLUSION Hospital mortality and hospital LOS of sepsis are similar to those reported in other observational studies. Our study confirms a decline in the mortality of sepsis predicted by earlier longitudinal studies and should prompt a resurgence of epidemiological research of the sepsis syndromes in the United States.
Collapse
Affiliation(s)
- Luis G Tulloch
- 1 Department of Medicine, University of Washington and Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - Jeannie D Chan
- 2 Department of Pharmacy, Harborview Medical Center, and School of Pharmacy, University of Washington, Seattle, WA, USA
| | - David J Carlbom
- 3 Division of Pulmonary and Critical Care Medicine, Department of Medicine, Harborview Medical Center and School of Medicine, University of Washington, Seattle, WA, USA
| | - Mary Jo Kelly
- 4 Department of Nursing, Harborview Medical Center, Seattle, WA, USA
| | - Timothy H Dellit
- 5 Division of Allergy & Infectious Diseases, Department of Medicine, Harborview Medical Center and School of Medicine, University of Washington, Seattle, WA, USA
| | - John B Lynch
- 5 Division of Allergy & Infectious Diseases, Department of Medicine, Harborview Medical Center and School of Medicine, University of Washington, Seattle, WA, USA
| |
Collapse
|
18
|
Choudhuri JA, Chan JD, Schreuder AB, Hafermann MJ, Fulton C, Melius E, McNamara E, Pergamit RF, Lynch JB, Dellit TH. Shared hoppers: a novel risk factor for the transmission of Clostridium difficile. Infect Control Hosp Epidemiol 2015; 35:1314-6. [PMID: 25203194 DOI: 10.1086/678077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Julie A Choudhuri
- Departments of Quality Improvement/Infection Control and Pharmacy, Harborview Medical Center, Seattle, Washington
| | | | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Chu HY, Englund JA, Huang D, Scott E, Chan JD, Jain R, Pottinger PS, Lynch JB, Dellit TH, Jerome KR, Kuypers J. Impact of rapid influenza PCR testing on hospitalization and antiviral use: A retrospective cohort study. J Med Virol 2015; 87:2021-6. [PMID: 26017150 DOI: 10.1002/jmv.24279] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2015] [Indexed: 11/08/2022]
Abstract
Rapid PCR-based influenza tests are increasingly used as point-of-care diagnostics in hospitals and clinics. To our knowledge, no prior studies have described clinical outcomes with implementation of rapid PCR-based influenza tests in hospitalized adult inpatients. Electronic medical records were used to assess differences in laboratory testing time and antiviral use among a subset of 175 consecutive adult inpatients tested for influenza in two respiratory seasons before and after implementation of rapid PCR-based influenza testing at an academic medical center. Of the 350 hospitalized inpatients included in this analysis, 96 (27%) were over 65 years of age and 308 (88%) had a comorbid condition. The overall time to result decreased significantly from 25.2 to 1.7 hr (P < 0.001) after implementation of rapid PCR-based influenza testing. Among influenza-negative patients, the frequency of oseltamivir initiation remained unchanged (before: 43% vs. after: 45%; P = 0.60), though the median duration of oseltamivir was significantly decreased from 1.1 to 0.0 days (P < 0.001). By providing an earlier result to clinicians, rapid PCR-based influenza tests may decrease unnecessary antiviral use among adult inpatients who test negative for influenza.
Collapse
Affiliation(s)
- Helen Y Chu
- Department of Medicine, University of Washington, Seattle, Washington
| | - Janet A Englund
- Department of Pediatrics, Seattle Children's Hospital, Seattle, Washington
| | - Dandi Huang
- Department of Medicine, University of Washington, Seattle, Washington
| | - Emily Scott
- Department of Medicine, University of Washington, Seattle, Washington
| | - Jeanne D Chan
- Department of Pharmacy, University of Washington, Seattle, Washington
| | - Rupali Jain
- Department of Pharmacy, University of Washington, Seattle, Washington
| | - Paul S Pottinger
- Department of Medicine, University of Washington, Seattle, Washington
| | - John B Lynch
- Department of Medicine, University of Washington, Seattle, Washington
| | - Timothy H Dellit
- Department of Medicine, University of Washington, Seattle, Washington
| | - Keith R Jerome
- Department of Laboratory Medicine, University of Washington, Seattle, Washington
| | - Jane Kuypers
- Department of Laboratory Medicine, University of Washington, Seattle, Washington
| |
Collapse
|
20
|
Harting BP, Talbot TR, Dellit TH, Hebden J, Cuny J, Greene WH, Segreti J. University HealthSystem Consortium Quality Performance Benchmarking Study of the Insertion and Care of Central Venous Catheters. Infect Control Hosp Epidemiol 2015; 29:440-2. [DOI: 10.1086/587716] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [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
We report data from an observational benchmarking study of adherence to recommended practices for insertion and maintenance of central venous catheters at a heterogeneous group of academic medical centers. These centers demonstrated a need for significant improvement in implementation and documentation of quality performance measures for the prevention of catheter-related bloodstream infections.
Collapse
|
21
|
Talbot TR, Dellit TH, Hebden J, Sama D, Cuny J. Factors Associated with Increased Healthcare Worker Influenza Vaccination
Rates: Results from a National Survey of University Hospitals and Medical
Centers. Infect Control Hosp Epidemiol 2015; 31:456-62. [DOI: 10.1086/651666] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [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
Objective.
To ascertain which components of healthcare worker (HCW) influenza
vaccination programs are associated with higher vaccination rates.
Design.
Survey.
Setting.
University-affiliated hospitals.
Methods.
Participating hospitals were surveyed with regard to their institutional
HCW influenza vaccination program for the 2007-2008 influenza season. Topics
assessed included vaccination adherence and availability, use of declination
statements, education methods, accountability, and data reporting. Factors
associated with higher vaccination rates were ascertained.
Results.
Fifty hospitals representing 368,696 HCWs participated in the project. The
median vaccination rate was 55.0% (range, 25.6%-80.6%); however, the types of
HCWs targeted by vaccination programs varied. Programs with the following
components had significantly higher vaccination rates: weekend provision of
vaccine (58.8% in those with this feature vs 43.9% in those without;
P = .01), train-the-trainer programs (59.5% vs
46.5%; P = .005), report of vaccination rates to
administrators (57.2% vs 48.1%; P = .04) or to the
board of trustees (63.9% vs 53.4%; P = .01), a
letter sent to employees emphasizing the importance of vaccination (59.3% vs
47%; P = .01), and any form of visible leadership
support (57.9% vs 36.9%; P = .01). Vaccination rates
were not significantly different between facilities that did and those that did
not require a signed declination form for HCWs who refused vaccination (56.9%
vs 55.1%; P = .68), although the precise content of
such statements varied.
Conclusions.
Vaccination programs that emphasized accountability to the highest levels
of the organization, provided weekend access to vaccination, and used
train-the-trainer programs had higher vaccination coverage. Of concern, the
types of HCWs targeted by vaccination programs differed, and uniform
definitions will be essential in the event of public reporting of vaccination
rates.
Collapse
|
22
|
Chu HY, Kuypers J, Dellit TH, Chan J, Lynch JB, Jain R, Pottinger P, Martin E, Englund JA. 1428Impact of Rapid Influenza PCR Testing on Inpatient Clinical Outcomes. Open Forum Infect Dis 2014. [DOI: 10.1093/ofid/ofu052.974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Helen Y. Chu
- Allergy and Infectious Diseases, University of Washington, Seattle, WA
| | | | | | | | - John B. Lynch
- Infection Control, Harborview Medical Center, Seattle, WA
| | - Rupali Jain
- Pharmacy, University of Washington Medical Center, Seattle, WA
| | - Paul Pottinger
- Division of Allergy and Infectious Disease, University of Washington, Seattle, WA
| | | | | |
Collapse
|
23
|
Jain R, Chan JD, Rogers L, Dellit TH, Lynch JB, Pottinger PS. High incidence of discontinuations due to adverse events in patients treated with ceftaroline. Pharmacotherapy 2014; 34:758-63. [PMID: 24807197 DOI: 10.1002/phar.1435] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
STUDY OBJECTIVE To determine clinical outcomes in patients who received ceftaroline (Teflaro) 600 mg intravenously every 8 or 12 hours after failing or developing intolerance to first-line agents including vancomycin, daptomycin, or linezolid. DESIGN Retrospective chart review and review of the literature. SETTING Large academic medical center and regional Level 1 trauma and burn center. PATIENTS Twelve patients who received ceftaroline for the treatment of refractory methicillin-resistant Staphylococcus aureus and coagulase-negative Staphylococcus infections between March 2011 and October 2012. MEASUREMENTS AND MAIN RESULTS Ceftaroline was discontinued in 9 (75%) of 12 patients secondary to adverse effects. The average age of patients who discontinued ceftaroline was 53 years, with a mean body mass index of 29 kg/m(2) and an average of four comorbidities (range one to eight). The median time to discontinuation due to perceived adverse effect was 22 days (range 5-62 days). The reasons for discontinuation of therapy were hematologic toxicities in seven patients and severe rash in two patients. Two patients completed therapy without documented adverse events, and one patient died on day 9 of ceftaroline therapy. CONCLUSION When given for off-label indications to 12 patients at our institutions, ceftaroline was associated with an unexpectedly high rate (75%) of discontinuation due to perceived adverse events, including hematologic toxicities and rash.
Collapse
Affiliation(s)
- Rupali Jain
- Department of Pharmacy, University of Washington Medical Center, Seattle, Washington; School of Pharmacy, University of Washington, Seattle, Washington
| | | | | | | | | | | |
Collapse
|
24
|
Morris AM, Brener S, Dresser L, Daneman N, Dellit TH, Avdic E, Bell CM. Use of a structured panel process to define quality metrics for antimicrobial stewardship programs. Infect Control Hosp Epidemiol 2012; 33:500-6. [PMID: 22476277 DOI: 10.1086/665324] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Antimicrobial stewardship programs are being implemented in health care to reduce inappropriate antimicrobial use, adverse events, Clostridium difficile infection, and antimicrobial resistance. There is no standardized approach to evaluate the impact of these programs. OBJECTIVE To use a structured panel process to define quality improvement metrics for evaluating antimicrobial stewardship programs in hospital settings that also have the potential to be used as part of public reporting efforts. DESIGN A multiphase modified Delphi technique. SETTING Paper-based survey supplemented with a 1-day consensus meeting. PARTICIPANTS A 10-member expert panel from Canada and the United States was assembled to evaluate indicators for relevance, effectiveness, and the potential to aid quality improvement efforts. RESULTS There were a total of 5 final metrics selected by the panel: (1) days of therapy per 1000 patient-days; (2) number of patients with specific organisms that are drug resistant; (3) mortality related to antimicrobial-resistant organisms; (4) conservable days of therapy among patients with community-acquired pneumonia (CAP), skin and soft-tissue infections (SSTI), or sepsis and bloodstream infections (BSI); and (5) unplanned hospital readmission within 30 days after discharge from the hospital in which the most responsible diagnosis was one of CAP, SSTI, sepsis or BSI. The first and second indicators were also identified as useful for accountability purposes, such as public reporting. CONCLUSION We have successfully identified 2 measures for public reporting purposes and 5 measures that can be used internally in healthcare settings as quality indicators. These indicators can be implemented across diverse healthcare systems to enable ongoing evaluation of antimicrobial stewardship programs and complement efforts for improved patient safety.
Collapse
Affiliation(s)
- Andrew M Morris
- Mount Sinai Hospital and University Health Network, Toronto, Ontario, Canada.
| | | | | | | | | | | | | |
Collapse
|
25
|
Choudhuri JA, Pergamit RF, Chan JD, Schreuder AB, McNamara E, Lynch JB, Dellit TH. An electronic catheter-associated urinary tract infection surveillance tool. Infect Control Hosp Epidemiol 2012; 32:757-62. [PMID: 21768758 DOI: 10.1086/661103] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To develop and validate an electronic surveillance tool for catheter-associated urinary tract infections (CAUTIs). DESIGN Retrospective cohort study. SETTING 413-bed university-affiliated urban teaching hospital. METHODS An electronic surveillance tool was developed for CAUTI and urinary catheter utilization based on the objective components of the National Healthcare Safety Network (NHSN) definitions including fever, urinalysis, and urine culture. Results were compared to manual chart review by an infection preventionist (IP). RESULTS During January and February 2010, 204 positive urine cultures (≥10(3) colony-forming units/mL) were identified in 136 patients with indwelling urinary catheters during their hospitalization. The electronic surveillance tool detected 60 CAUTI cases and 7,098 catheter-days, yielding a CAUTI incidence rate of 8.5 per 1,000 catheter-days. Urinary catheter utilization ratios (Foley-days/patient-days) were: acute care units, 0.27 (3,637 of 13,229); intensive care units, 0.77 (3,461 of 4,469); and overall, 0.40 (7,098 of 17,698). In comparison, the IP identified 59 cases by manual review with a sensitivity of 51 of 59 (86.4%), specificity 136 of 145 (93.8%), and negative predictive value of 136 of 144 (94.4%). Fever was present in 54 of 59 (91.5%) of CAUTI cases identified manually, while subjective criteria were documented in only 6 of 59 (10.2%) infections. Agreement between the electronic surveillance and manual IP review was assessed as very good (κ, 0.80; 95% confidence interval, 0.71-0.89). CONCLUSIONS We report an attempt at automating surveillance for CAUTI. With a high negative predictive value, the electronic tool allows for more efficient CAUTI surveillance and facilitates housewide trending of rates and catheter utilization. This approach should be validated in different patient populations.
Collapse
Affiliation(s)
- Julie A Choudhuri
- Department of Quality Improvement/Infection Control, Harborview Medical Center, Seattle, Washington 98104, USA
| | | | | | | | | | | | | |
Collapse
|
26
|
Clemens EC, Chan JD, Lynch JB, Dellit TH. Relationships between vancomycin minimum inhibitory concentration, dosing strategies, and outcomes in methicillin-resistant Staphylococcus aureus bacteremia. Diagn Microbiol Infect Dis 2011; 71:408-14. [PMID: 21924852 DOI: 10.1016/j.diagmicrobio.2011.08.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2011] [Revised: 07/22/2011] [Accepted: 08/01/2011] [Indexed: 10/17/2022]
Abstract
Retrospective study aimed to examine outcomes of methicillin-resistant Staphylococcus aureus (MRSA) bacteremia in relationship to vancomycin minimum inhibitory concentration (VAN MIC) and serum trough concentrations among subjects who had ≥1 blood culture positive for MRSA between April 2008 and August 2009. Treatment failure occurred in 7/24 (29%) subjects with VAN MIC = 2 mg/L versus 20/94 (21%) subjects with VAN MIC ≤1.5 mg/L (adjusted OR 1.11, 95% confidence interval [CI] 0.24-5.14). Among subjects who had documented VAN serum trough concentrations, treatment failure occurred in 5/26 (19%) subjects with concentrations <15 mg/L versus 18/68 (27%) subjects with concentrations ≥15 mg/L (adjusted OR 0.91, 95% CI 0.21-3.84). In conclusion, treatment outcomes were similar regardless of VAN MIC, although there was a non-statistically significant trend towards decreased clinical efficacy among patients with VAN MIC = 2 mg/L. Optimization of VAN pharmacokinetic indices did not appear to correlate with clinical responses.
Collapse
Affiliation(s)
- Evan C Clemens
- Department of Pharmacy, Harborview Medical Center and School of Pharmacy, University of Washington, Seattle, WA 98104, USA
| | | | | | | |
Collapse
|
27
|
Chan JD, Pham TN, Wong J, Hessel M, Cuschieri J, Neff M, Dellit TH. Clinical outcomes of linezolid vs vancomycin in methicillin-resistant Staphylococcus aureus ventilator-associated pneumonia: retrospective analysis. J Intensive Care Med 2011; 26:385-91. [PMID: 21606058 DOI: 10.1177/0885066610392893] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Vancomycin has been the treatment standard for methicillin-resistant Staphylococcus aureus (MRSA) infections, but clinical efficacy is limited. We report outcomes of a cohort with MRSA ventilator-associated pneumonia (VAP) treated with vancomycin vs linezolid. METHODS Retrospective analysis of 113 participants with MRSA VAP confirmed by bronchoscopy who have been initiated on therapy with either vancomycin or linezolid within 24 hours after bronchoscopy and completed ≥7 days of therapy during their hospitalization from July 2003 to June 2007. The primary endpoints were hospital survival and clinical cure, defined as resolution of signs and symptoms of VAP or microbiological eradication after completion of therapy along with clinical pulmonary infection score (CPIS) ≤6 at day 7 of therapy. RESULTS At hospital discharge, 23/27 (85.2%) of linezolid and 72/86 (83.7%) of vancomycin recipients had survived (P = .672). In comparison to linezolid recipients, the adjusted odds ratio (OR) for survival was 0.72 (95% confidence interval [CI]: 0.16-3.27) with vancomycin therapy. Clinical cure was achieved in 24/27 (88.9%) of linezolid and 63/86 (73.3%) of vancomycin recipients (P = .066). Compared to linezolid recipients, the adjusted OR for clinical cure was 0.24 (95% CI: 0.05-1.10) with vancomycin therapy. Survival and clinical cure did not differ significantly between vancomycin recipients with trough level ≥15 and <15 μg/mL, respectively. CONCLUSIONS Our results suggested no survival benefit but a trend toward higher cure rate with linezolid therapy. The optimal treatment of MRSA VAP requires further study through randomized, controlled trials.
Collapse
Affiliation(s)
- Jeannie D Chan
- Department of Pharmacy, Harborview Medical Center, and School of Pharmacy, University of Washington, Seattle, WA 98104, USA.
| | | | | | | | | | | | | |
Collapse
|
28
|
Schleyer AM, Jarman KM, Chan JD, Dellit TH. Role of nasal methicillin-resistant Staphylococcus aureus screening in the management of skin and soft tissue infections. Am J Infect Control 2010; 38:657-9. [PMID: 20416973 DOI: 10.1016/j.ajic.2010.01.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2009] [Revised: 01/15/2010] [Accepted: 01/19/2010] [Indexed: 10/19/2022]
Abstract
We set out to determine whether nasal swab isolates can identify methicillin-resistant Staphylococcus aureus (MRSA) colonization and guide therapy in skin and soft tissue infections (SSTI). Among hospitalized patients admitted to a general medicine service with SSTI, specificity and positive predictive value for MRSA in nasal swab isolates were 100%; sensitivity was 55%. Thus, positive nasal swab cultures may help identify MRSA colonization and guide antimicrobial therapy for SSTI when wound cultures cannot be obtained.
Collapse
|
29
|
Chan JD, Graves JA, Dellit TH. Antimicrobial Treatment and Clinical Outcomes of Carbapenem-Resistant Acinetobacter baumannii Ventilator-Associated Pneumonia. J Intensive Care Med 2010; 25:343-8. [DOI: 10.1177/0885066610377975] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives: Carbapenem-resistant (CR) Acinetobacter baumannii is an important pathogen in ventilator-associated pneumonia (VAP), but therapeutic options are limited. We describe the clinical outcomes of the largest case series of CR-Acinetobacter VAP reported to date. Methods: A retrospective analysis of 55 participants with CR-Acinetobacter VAP from July 2004 to December 2007 was undertaken. The primary endpoint was clinical response or microbiological eradication. Secondary endpoint was treatment-associated nephrotoxicity defined as ≥50% increase in serum creatinine or an increase of ≥0.5 mg/dL during therapy. Results: Forty-two (76.4%) participants achieved clinical response at the completion of therapy. Clinical responses were achieved in 60.0% of sulbactam-based, 66.7% of polymyxin-based, 77.8% of aminoglycoside-based, 80.6% of minocycline-based, and 90.0% of tigecycline-based regimens. Follow-up sputum cultures were available in 6 of 10 tigecycline-treated participants with 4 of 6 isolates developing intermediate resistance to tigecycline while on therapy. Ten (18.2%) participants without preexisting renal disease developed treatment-associated nephrotoxicity. Baseline serum creatinine was 0.9 ± 0.1 mg/dL (range: 0.6-1.0 mg/dL) at the start of therapy and peaked at 1.9 ± 0.5 mg/dL (range: 1.6-3.0 mg/dL) during therapy. After excluding other potential concomitant renal toxic agents, nephrotoxicity developed in 6 of 30 (20.0%) and 4 of 7 (57.1%) participants treated with an aminoglycoside-or polymyxin-based regimen, respectively. Conclusions: Our results demonstrated that CR-Acinetobacter VAP can be effectively treated with second-line agents. However, colistin-related nephrotoxicity was much higher than recently reported and decreased susceptibility to tigecycline emerged on therapy demonstrating the limitations of alternative regimens.
Collapse
Affiliation(s)
- Jeannie D. Chan
- Department of Pharmacy, Harborview Medical Center, and School of Pharmacy, University of Washington, Seattle, WA, USA,
| | | | - Timothy H. Dellit
- Department of Medicine, Division of Allergy & Infectious Diseases, Harborview Medical Center and School of Medicine, University of Washington, Seattle, WA, USA
| |
Collapse
|
30
|
Gulati RK, Choudhuri J, Fulton C, Chan JD, Evans HL, Lynch JB, Dellit TH. Outbreak of carbapenem-resistant Acinetobacter baumannii among non-burn patients in a burn intensive care unit. J Hosp Infect 2010; 76:357-8. [PMID: 20580125 DOI: 10.1016/j.jhin.2010.04.005] [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] [Received: 04/08/2010] [Accepted: 04/22/2010] [Indexed: 10/19/2022]
|
31
|
Kim HN, Harrington RD, Crane HM, Dhanireddy S, Dellit TH, Spach DH. Hepatitis B vaccination in HIV-infected adults: current evidence, recommendations and practical considerations. Int J STD AIDS 2009; 20:595-600. [PMID: 19710329 DOI: 10.1258/ijsa.2009.009126] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Immunization with hepatitis B (HBV) vaccine is recommended for all HIV-infected individuals without immunity to HBV. This patient population, however, has relatively poor HBV vaccine responses. Factors associated with this impaired HBV vaccine response in HIV-infected individuals may include older age, uncontrolled HIV replication, and low nadir CD4 cell count. Postvaccination testing for HBV surface antibody is recommended and vaccine non-responders should undergo repeat immunization with a full series. The benefit of double dosage, the appropriate strategy for HIV-infected patients with isolated HBV core antibody and the timing and number of vaccinations in persons with advanced immunosuppression on highly active antiretroviral therapy remain controversial areas.
Collapse
Affiliation(s)
- H N Kim
- Division of Allergy & Infectious Diseases, Department of Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA.
| | | | | | | | | | | |
Collapse
|
32
|
Pope SD, Dellit TH, Owens RC, Hooton TM. Results of survey on implementation of Infectious Diseases Society of America and Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Infect Control Hosp Epidemiol 2009; 30:97-8. [PMID: 19046053 DOI: 10.1086/592979] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
|
33
|
Binswanger IA, Takahashi TA, Bradley K, Dellit TH, Benton KL, Merrill JO. Drug users seeking emergency care for soft tissue infection at high risk for subsequent hospitalization and death. J Stud Alcohol Drugs 2008; 69:924-32. [PMID: 18925351 PMCID: PMC2583377 DOI: 10.15288/jsad.2008.69.924] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [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: 01/31/2008] [Revised: 05/27/2008] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Although soft tissue infections are common among injection drug users (IDUs), little is known about the health outcomes among those who seek care for these infections. Emergency department visits are an important point-of-health-care contact for IDUs. In this prospective cohort study, we aimed to determine the hospitalization and mortality rates and factors associated with hospitalization or death among IDUs seeking emergency care for soft tissue infection. METHOD Participants were English-speaking IDUs, 18 years of age and older, who sought initial care for soft tissue infection in an urban emergency department. We conducted semistructured interviews, identified hospitalizations from hospital records, and identified deaths using the National Death Index. Cox proportional hazards regression was used to investigate associations between baseline characteristics and hospitalizations or death. RESULTS Of 211 eligible patients, 156 (74%) participated (mean age = 42 years). There were 255 subsequent hospitalizations over a mean of 3.9 years follow-up. The hospitalization rate was 42 hospitalizations per 100 person-years (95% confidence interval [CI]: 38-48). The mortality rate was 2.0 per 100 person-years (95% CI: 1.1-3.7). Factors associated with increased risk for hospitalization or death included living on the street or in a shelter (adjusted odds ratio [AOR] = 1.75, 95% CI: 1.10-2.79), being recently incarcerated (AOR = 1.90, 95% CI: 1.05-3.44), and having insurance (AOR: 1.98, 95% CI: 1.22-3.23). CONCLUSIONS IDUs who sought care in the emergency department for soft tissue infections were at high risk for subsequent hospitalization and death. Visits for soft tissue infections represent missed opportunities for preventive care.
Collapse
Affiliation(s)
- Ingrid A. Binswanger
- Division of General Internal Medicine, School of Medicine, University of Colorado Denver, Mail Stop B180, AO1,12631 East 17th Avenue, Aurora, Colorado 80045
| | - Traci A. Takahashi
- Division of General Internal Medicine, School of Medicine, University of Colorado Denver, Mail Stop B180, AO1,12631 East 17th Avenue, Aurora, Colorado 80045
| | - Katharine Bradley
- Division of General Internal Medicine, School of Medicine, University of Colorado Denver, Mail Stop B180, AO1,12631 East 17th Avenue, Aurora, Colorado 80045
| | - Timothy H. Dellit
- Division of General Internal Medicine, School of Medicine, University of Colorado Denver, Mail Stop B180, AO1,12631 East 17th Avenue, Aurora, Colorado 80045
| | - Kathryn L. Benton
- Division of General Internal Medicine, School of Medicine, University of Colorado Denver, Mail Stop B180, AO1,12631 East 17th Avenue, Aurora, Colorado 80045
| | - Joseph O. Merrill
- Division of General Internal Medicine, School of Medicine, University of Colorado Denver, Mail Stop B180, AO1,12631 East 17th Avenue, Aurora, Colorado 80045
| |
Collapse
|
34
|
Dellit TH, Chan JD, Skerrett SJ, Nathens AB. Development of a guideline for the management of ventilator-associated pneumonia based on local microbiologic findings and impact of the guideline on antimicrobial use practices. Infect Control Hosp Epidemiol 2008; 29:525-33. [PMID: 18510462 DOI: 10.1086/588160] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To describe the development of a guideline for the management of ventilator-associated pneumonia (VAP) based on local microbiologic findings and to evaluate the impact of the guideline on antimicrobial use practices. DESIGN Retrospective comparison of antimicrobial use practices before and after implementation of the guideline. SETTING Intensive care units at Harborview Medical Center, Seattle, Washington, a university-affiliated urban teaching hospital. PATIENTS A total of 819 patients who received mechanical ventilation and who underwent quantitative bronchoscopy between July 1, 2003, and June 30, 2005, for suspected VAP. INTERVENTIONS Implementation of an evidence-based VAP guideline that focused on the use of quantitative bronchoscopy for diagnosis, administration of empirical antimicrobial therapy based on local microbiologic findings and resistance patterns, tailoring definitive antimicrobial therapy on the basis of culture results, and appropriate duration of therapy. RESULTS During the baseline period, 168 (46.7%) of 360 patients had quantitative cultures that met the diagnostic criteria for VAP, compared with 216 (47.1%) of 459 patients in the period after the guideline was implemented. The pathogens responsible for VAP remained similar between the 2 periods, except that the prevalence of VAP due to carbapenem-resistant Acinetobacter species increased from 1.8% to 15.3% (P<.001), particularly in late-onset VAP. Compared with the baseline period, there was an improvement in antimicrobial use practices after implementation of the guideline: antimicrobial therapy was more frequently tailored on the basis of quantitative culture results (103 [61.3%] of 168 vs 150 [69.4%] of 216 patients; P = .034), there was an increase in the use of appropriate definitive therapy (135 [80.4%] of 168 vs 193 [89.4%] of 216 patients; P = .001), and there was a decrease in the mean duration of therapy (12.0 vs 10.7 days; P = .0014). The all-cause mortality rate was similar in the periods before and after the guideline was implemented (38 [22.6%] of 168 vs 46 [21.3%] of 216 patients; P = .756). CONCLUSIONS Implementation of a guideline for the management of VAP that incorporated the use of quantitative bronchoscopy, the use of empirical therapy based on local microbiologic findings, tailoring of therapy on the basis of culture results, and use of shortened durations of therapy led to significant improvements in antimicrobial use practices without adversely affecting the all-cause mortality rate.
Collapse
|
35
|
Dellit TH, Owens RC, McGowan JE, Gerding DN, Weinstein RA, Burke JP, Huskins WC, Paterson DL, Fishman NO, Carpenter CF, Brennan PJ, Billeter M, Hooton TM. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2006; 44:159-77. [PMID: 17173212 DOI: 10.1086/510393] [Citation(s) in RCA: 2281] [Impact Index Per Article: 126.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2006] [Accepted: 10/04/2006] [Indexed: 12/31/2022] Open
Affiliation(s)
- Timothy H Dellit
- Harborview Medical Center and the University of Washington, Seattle, USA
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
36
|
|