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Gohil SK, Septimus E, Kleinman K, Varma N, Avery TR, Heim L, Rahm R, Cooper WS, Cooper M, McLean LE, Nickolay NG, Weinstein RA, Burgess LH, Coady MH, Rosen E, Sljivo S, Sands KE, Moody J, Vigeant J, Rashid S, Gilbert RF, Smith KN, Carver B, Poland RE, Hickok J, Sturdevant SG, Calderwood MS, Weiland A, Kubiak DW, Reddy S, Neuhauser MM, Srinivasan A, Jernigan JA, Hayden MK, Gowda A, Eibensteiner K, Wolf R, Perlin JB, Platt R, Huang SS. Stewardship Prompts to Improve Antibiotic Selection for Pneumonia: The INSPIRE Randomized Clinical Trial. JAMA 2024:2817976. [PMID: 38639729 DOI: 10.1001/jama.2024.6248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
Importance Pneumonia is the most common infection requiring hospitalization and is a major reason for overuse of extended-spectrum antibiotics. Despite low risk of multidrug-resistant organism (MDRO) infection, clinical uncertainty often drives initial antibiotic selection. Strategies to limit empiric antibiotic overuse for patients with pneumonia are needed. Objective To evaluate whether computerized provider order entry (CPOE) prompts providing patient- and pathogen-specific MDRO infection risk estimates could reduce empiric extended-spectrum antibiotics for non-critically ill patients admitted with pneumonia. Design, Setting, and Participants Cluster-randomized trial in 59 US community hospitals comparing the effect of a CPOE stewardship bundle (education, feedback, and real-time MDRO risk-based CPOE prompts; n = 29 hospitals) vs routine stewardship (n = 30 hospitals) on antibiotic selection during the first 3 hospital days (empiric period) in non-critically ill adults (≥18 years) hospitalized with pneumonia. There was an 18-month baseline period from April 1, 2017, to September 30, 2018, and a 15-month intervention period from April 1, 2019, to June 30, 2020. Intervention CPOE prompts recommending standard-spectrum antibiotics in patients ordered to receive extended-spectrum antibiotics during the empiric period who have low estimated absolute risk (<10%) of MDRO pneumonia, coupled with feedback and education. Main Outcomes and Measures The primary outcome was empiric (first 3 days of hospitalization) extended-spectrum antibiotic days of therapy. Secondary outcomes included empiric vancomycin and antipseudomonal days of therapy and safety outcomes included days to intensive care unit (ICU) transfer and hospital length of stay. Outcomes compared differences between baseline and intervention periods across strategies. Results Among 59 hospitals with 96 451 (51 671 in the baseline period and 44 780 in the intervention period) adult patients admitted with pneumonia, the mean (SD) age of patients was 68.1 (17.0) years, 48.1% were men, and the median (IQR) Elixhauser comorbidity count was 4 (2-6). Compared with routine stewardship, the group using CPOE prompts had a 28.4% reduction in empiric extended-spectrum days of therapy (rate ratio, 0.72 [95% CI, 0.66-0.78]; P < .001). Safety outcomes of mean days to ICU transfer (6.5 vs 7.1 days) and hospital length of stay (6.8 vs 7.1 days) did not differ significantly between the routine and CPOE intervention groups. Conclusions and Relevance Empiric extended-spectrum antibiotic use was significantly lower among adults admitted with pneumonia to non-ICU settings in hospitals using education, feedback, and CPOE prompts recommending standard-spectrum antibiotics for patients at low risk of MDRO infection, compared with routine stewardship practices. Hospital length of stay and days to ICU transfer were unchanged. Trial Registration ClinicalTrials.gov Identifier: NCT03697070.
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Affiliation(s)
- Shruti K Gohil
- Division of Infectious Diseases, University of California, Irvine School of Medicine, Irvine
| | - Edward Septimus
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
| | - Ken Kleinman
- Biostatistics and Epidemiology, University of Massachusetts, Amherst
| | - Neha Varma
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Boston, Massachusetts
| | - Taliser R Avery
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
| | - Lauren Heim
- Division of Infectious Diseases, University of California, Irvine School of Medicine, Irvine
| | - Risa Rahm
- HCA Healthcare, Nashville, Tennessee
| | | | | | | | | | | | | | - Micaela H Coady
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Boston, Massachusetts
| | - Edward Rosen
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Boston, Massachusetts
| | - Selsebil Sljivo
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Boston, Massachusetts
| | - Kenneth E Sands
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
- HCA Healthcare, Nashville, Tennessee
| | | | - Justin Vigeant
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Boston, Massachusetts
| | - Syma Rashid
- Division of Infectious Diseases, University of California, Irvine School of Medicine, Irvine
| | - Rebecca F Gilbert
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Boston, Massachusetts
| | | | | | - Russell E Poland
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
- HCA Healthcare, Nashville, Tennessee
| | | | | | - Michael S Calderwood
- Section of Infectious Disease and International Health, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Anastasiia Weiland
- Division of Infectious Diseases, University of California, Irvine School of Medicine, Irvine
| | | | - Sujan Reddy
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | - John A Jernigan
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Abinav Gowda
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Boston, Massachusetts
| | - Katyuska Eibensteiner
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Boston, Massachusetts
| | - Robert Wolf
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Boston, Massachusetts
| | - Jonathan B Perlin
- HCA Healthcare, Nashville, Tennessee
- Now with The Joint Commission, Oakbrook Terrace, Illinois
| | - Richard Platt
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
| | - Susan S Huang
- Division of Infectious Diseases, University of California, Irvine School of Medicine, Irvine
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Gohil SK, Septimus E, Kleinman K, Varma N, Avery TR, Heim L, Rahm R, Cooper WS, Cooper M, McLean LE, Nickolay NG, Weinstein RA, Burgess LH, Coady MH, Rosen E, Sljivo S, Sands KE, Moody J, Vigeant J, Rashid S, Gilbert RF, Smith KN, Carver B, Poland RE, Hickok J, Sturdevant SG, Calderwood MS, Weiland A, Kubiak DW, Reddy S, Neuhauser MM, Srinivasan A, Jernigan JA, Hayden MK, Gowda A, Eibensteiner K, Wolf R, Perlin JB, Platt R, Huang SS. Stewardship Prompts to Improve Antibiotic Selection for Urinary Tract Infection: The INSPIRE Randomized Clinical Trial. JAMA 2024:2817975. [PMID: 38639723 DOI: 10.1001/jama.2024.6259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
Importance Urinary tract infection (UTI) is the second most common infection leading to hospitalization and is often associated with gram-negative multidrug-resistant organisms (MDROs). Clinicians overuse extended-spectrum antibiotics although most patients are at low risk for MDRO infection. Safe strategies to limit overuse of empiric antibiotics are needed. Objective To evaluate whether computerized provider order entry (CPOE) prompts providing patient- and pathogen-specific MDRO risk estimates could reduce use of empiric extended-spectrum antibiotics for treatment of UTI. Design, Setting, and Participants Cluster-randomized trial in 59 US community hospitals comparing the effect of a CPOE stewardship bundle (education, feedback, and real-time and risk-based CPOE prompts; 29 hospitals) vs routine stewardship (n = 30 hospitals) on antibiotic selection during the first 3 hospital days (empiric period) in noncritically ill adults (≥18 years) hospitalized with UTI with an 18-month baseline (April 1, 2017-September 30, 2018) and 15-month intervention period (April 1, 2019-June 30, 2020). Interventions CPOE prompts recommending empiric standard-spectrum antibiotics in patients ordered to receive extended-spectrum antibiotics who have low estimated absolute risk (<10%) of MDRO UTI, coupled with feedback and education. Main Outcomes and Measures The primary outcome was empiric (first 3 days of hospitalization) extended-spectrum antibiotic days of therapy. Secondary outcomes included empiric vancomycin and antipseudomonal days of therapy. Safety outcomes included days to intensive care unit (ICU) transfer and hospital length of stay. Outcomes were assessed using generalized linear mixed-effect models to assess differences between the baseline and intervention periods. Results Among 127 403 adult patients (71 991 baseline and 55 412 intervention period) admitted with UTI in 59 hospitals, the mean (SD) age was 69.4 (17.9) years, 30.5% were male, and the median Elixhauser Comorbidity Index count was 4 (IQR, 2-5). Compared with routine stewardship, the group using CPOE prompts had a 17.4% (95% CI, 11.2%-23.2%) reduction in empiric extended-spectrum days of therapy (rate ratio, 0.83 [95% CI, 0.77-0.89]; P < .001). The safety outcomes of mean days to ICU transfer (6.6 vs 7.0 days) and hospital length of stay (6.3 vs 6.5 days) did not differ significantly between the routine and intervention groups, respectively. Conclusions and Relevance Compared with routine stewardship, CPOE prompts providing real-time recommendations for standard-spectrum antibiotics for patients with low MDRO risk coupled with feedback and education significantly reduced empiric extended-spectrum antibiotic use among noncritically ill adults admitted with UTI without changing hospital length of stay or days to ICU transfers. Trial Registration ClinicalTrials.gov Identifier: NCT03697096.
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Affiliation(s)
- Shruti K Gohil
- Division of Infectious Diseases, University of California, Irvine School of Medicine, Irvine
| | - Edward Septimus
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
| | - Ken Kleinman
- Biostatistics and Epidemiology, University of Massachusetts, Amherst
| | - Neha Varma
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Taliser R Avery
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
| | - Lauren Heim
- Division of Infectious Diseases, University of California, Irvine School of Medicine, Irvine
| | - Risa Rahm
- HCA Healthcare, Nashville, Tennessee
| | | | | | | | | | | | | | - Micaela H Coady
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Edward Rosen
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Selsebil Sljivo
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Kenneth E Sands
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
- HCA Healthcare, Nashville, Tennessee
| | | | - Justin Vigeant
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Syma Rashid
- Division of Infectious Diseases, University of California, Irvine School of Medicine, Irvine
| | - Rebecca F Gilbert
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | | | | | - Russell E Poland
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
- HCA Healthcare, Nashville, Tennessee
| | | | | | - Michael S Calderwood
- Section of Infectious Disease and International Health, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Anastasiia Weiland
- Division of Infectious Diseases, University of California, Irvine School of Medicine, Irvine
| | | | - Sujan Reddy
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | - John A Jernigan
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Abinav Gowda
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Katyuska Eibensteiner
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Robert Wolf
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Jonathan B Perlin
- HCA Healthcare, Nashville, Tennessee
- Now with The Joint Commission, Oakbrook Terrace, Illinois
| | - Richard Platt
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
| | - Susan S Huang
- Division of Infectious Diseases, University of California, Irvine School of Medicine, Irvine
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Huang SS, Septimus EJ, Kleinman K, Heim LT, Moody JA, Avery TR, McLean L, Rashid S, Haffenreffer K, Shimelman L, Staub-Juergens W, Spencer-Smith C, Sljivo S, Rosen E, Poland RE, Coady MH, Lee CH, Blanchard EJ, Reddish K, Hayden MK, Weinstein RA, Carver B, Smith K, Hickok J, Lolans K, Khan N, Sturdevant SG, Reddy SC, Jernigan JA, Sands KE, Perlin JB, Platt R. Nasal Iodophor Antiseptic vs Nasal Mupirocin Antibiotic in the Setting of Chlorhexidine Bathing to Prevent Infections in Adult ICUs: A Randomized Clinical Trial. JAMA 2023; 330:1337-1347. [PMID: 37815567 PMCID: PMC10565599 DOI: 10.1001/jama.2023.17219] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 08/17/2023] [Indexed: 10/11/2023]
Abstract
Importance Universal nasal mupirocin plus chlorhexidine gluconate (CHG) bathing in intensive care units (ICUs) prevents methicillin-resistant Staphylococcus aureus (MRSA) infections and all-cause bloodstream infections. Antibiotic resistance to mupirocin has raised questions about whether an antiseptic could be advantageous for ICU decolonization. Objective To compare the effectiveness of iodophor vs mupirocin for universal ICU nasal decolonization in combination with CHG bathing. Design, Setting, and Participants Two-group noninferiority, pragmatic, cluster-randomized trial conducted in US community hospitals, all of which used mupirocin-CHG for universal decolonization in ICUs at baseline. Adult ICU patients in 137 randomized hospitals during baseline (May 1, 2015-April 30, 2017) and intervention (November 1, 2017-April 30, 2019) were included. Intervention Universal decolonization involving switching to iodophor-CHG (intervention) or continuing mupirocin-CHG (baseline). Main Outcomes and Measures ICU-attributable S aureus clinical cultures (primary outcome), MRSA clinical cultures, and all-cause bloodstream infections were evaluated using proportional hazard models to assess differences from baseline to intervention periods between the strategies. Results were also compared with a 2009-2011 trial of mupirocin-CHG vs no decolonization in the same hospital network. The prespecified noninferiority margin for the primary outcome was 10%. Results Among the 801 668 admissions in 233 ICUs, the participants' mean (SD) age was 63.4 (17.2) years, 46.3% were female, and the mean (SD) ICU length of stay was 4.8 (4.7) days. Hazard ratios (HRs) for S aureus clinical isolates in the intervention vs baseline periods were 1.17 for iodophor-CHG (raw rate: 5.0 vs 4.3/1000 ICU-attributable days) and 0.99 for mupirocin-CHG (raw rate: 4.1 vs 4.0/1000 ICU-attributable days) (HR difference in differences significantly lower by 18.4% [95% CI, 10.7%-26.6%] for mupirocin-CHG, P < .001). For MRSA clinical cultures, HRs were 1.13 for iodophor-CHG (raw rate: 2.3 vs 2.1/1000 ICU-attributable days) and 0.99 for mupirocin-CHG (raw rate: 2.0 vs 2.0/1000 ICU-attributable days) (HR difference in differences significantly lower by 14.1% [95% CI, 3.7%-25.5%] for mupirocin-CHG, P = .007). For all-pathogen bloodstream infections, HRs were 1.00 (2.7 vs 2.7/1000) for iodophor-CHG and 1.01 (2.6 vs 2.6/1000) for mupirocin-CHG (nonsignificant HR difference in differences, -0.9% [95% CI, -9.0% to 8.0%]; P = .84). Compared with the 2009-2011 trial, the 30-day relative reduction in hazards in the mupirocin-CHG group relative to no decolonization (2009-2011 trial) were as follows: S aureus clinical cultures (current trial: 48.1% [95% CI, 35.6%-60.1%]; 2009-2011 trial: 58.8% [95% CI, 47.5%-70.7%]) and bloodstream infection rates (current trial: 70.4% [95% CI, 62.9%-77.8%]; 2009-2011 trial: 60.1% [95% CI, 49.1%-70.7%]). Conclusions and Relevance Nasal iodophor antiseptic did not meet criteria to be considered noninferior to nasal mupirocin antibiotic for the outcome of S aureus clinical cultures in adult ICU patients in the context of daily CHG bathing. In addition, the results were consistent with nasal iodophor being inferior to nasal mupirocin. Trial Registration ClinicalTrials.gov Identifier: NCT03140423.
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Affiliation(s)
- Susan S. Huang
- University of California Irvine School of Medicine, Irvine
| | - Edward J. Septimus
- Harvard Medical School and Harvard Pilgrim Health Care, Boston, Massachusetts
- Texas A&M College of Medicine and Memorial Hermann Health System, Houston
| | | | - Lauren T. Heim
- University of California Irvine School of Medicine, Irvine
| | | | - Taliser R. Avery
- Harvard Medical School and Harvard Pilgrim Health Care, Boston, Massachusetts
| | | | - Syma Rashid
- University of California Irvine School of Medicine, Irvine
| | | | - Lauren Shimelman
- Harvard Medical School and Harvard Pilgrim Health Care, Boston, Massachusetts
| | | | | | - Selsebil Sljivo
- Harvard Medical School and Harvard Pilgrim Health Care, Boston, Massachusetts
| | - Ed Rosen
- Harvard Medical School and Harvard Pilgrim Health Care, Boston, Massachusetts
| | | | - Micaela H. Coady
- Harvard Medical School and Harvard Pilgrim Health Care, Boston, Massachusetts
| | | | | | | | | | - Robert A. Weinstein
- Rush Medical College, Chicago, Illinois
- John H. Stroger Jr. Hospital of Cook County, Chicago, Illinois
| | | | | | | | | | | | - S. Gwynn Sturdevant
- University of Massachusetts Amherst
- now with Wharton School of the University of Pennsylvania, Philadelphia
| | - Sujan C. Reddy
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | - Jonathan B. Perlin
- HCA Healthcare, Nashville, Tennessee
- now with The Joint Commission, Oakbrook Terrace, Illinois
| | - Richard Platt
- Harvard Medical School and Harvard Pilgrim Health Care, Boston, Massachusetts
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4
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Gohil SK, Septimus E, Kleinman K, Varma N, Heim L, Rashid S, Rahm R, Cooper WS, Nickolay NG, McLean LE, Weinstein RA, Rosen E, Avery TR, Selsebil S, Vigeant J, Sands K, Cooper M, Burgess HL, Moody J, Coady MH, Rebecca GF, Smith KN, Carver B, Spencer-Smith C, Poland R, Hickok J, Sturdevant SG, Weiland A, Gowda A, Wolf R, Hayden MK, Reddy S, Neuhauser MM, Srinivasan A, Srinivasan A, Kubiak DW, Jernigan JA, Jernigan JA, Perlin JB, Platt R, Huang SS. 13. INSPIRE-ASP Pneumonia Trial: A 59 Hospital Cluster Randomized Evaluation of INtelligent Stewardship Prompts to Improve Real-time Empiric Antibiotic Selection versus Routine Antibiotic Selection Practices for Patients with Pneumonia. Open Forum Infect Dis 2021. [PMCID: PMC8643995 DOI: 10.1093/ofid/ofab466.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Up to 40% of hospitalized patients receive unnecessary or inappropriately broad antibiotics despite a low risk of multidrug-resistant organism (MDRO) infection. Empiric standard spectrum antibiotic use would reduce extended-spectrum (ES) antibiotic exposure and future resistance. We evaluated whether computerized prescriber order entry prompts providing patient-specific MDRO risk estimates could reduce ES antibiotic use compared to routine stewardship practices in patients hospitalized with pneumonia. Methods This 59 hospital cluster-randomized trial compared: 1) INSPIRE prompts providing patient-specific MDRO pneumonia risk estimates at order entry and recommended standard spectrum antibiotics for risk < 10% versus 2) routine stewardship practices. Prompt used an absolute MDRO risk algorithm based on a 140 hospital data set. Trial population included adults treated with antibiotics for pneumonia in ED or non-ICU wards in first 3 days of admission (empiric days); prompt was triggered if ES antibiotics were ordered. Prescribers received feedback on prompt response. Trial periods: 18-month Baseline (Apr 2017–Sept 2018); 6-month Phase-in (Oct 2018–Mar 2019); 15-month Intervention (Apr 2019 – June 2020). Primary outcome was ES antibiotic days of therapy (ES-DOT) per empiric day; secondary outcomes were a) vancomycin and b) anti-pseudomonal DOT per empiric day. Unadjusted, as-randomized analyses used generalized linear mixed effects models to assess differences in ES-DOT rates between the intervention vs baseline period across arms (difference in differences), while clustering by patient and hospital. Results We randomized 59 hospitals in 12 states, with 59,897 and 51,486 non-ICU pneumonia admissions in baseline and intervention periods, respectively. Intervention group had a 33% reduction in ES-DOT compared to routine care. Vancomycin and anti-pseudomonal DOT were similarly reduced in the intervention group by 27% and 33%, respectively (Table). ![]()
Conclusion INSPIRE order entry prompts providing real-time, patient-specific MDRO risk estimates with recommendation to use standard spectrum antibiotics in low risk patients significantly reduced empiric ES prescribing in adults admitted with pneumonia. Disclosures Shruti K. Gohil, MD, MPH, Medline (Other Financial or Material Support, Co-Investigator in studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Molnycke (Other Financial or Material Support, Co-Investigator in studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Stryker (Sage) (Other Financial or Material Support, Co-Investigator in studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products) Edward Septimus, MD, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic products)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic products) Ken Kleinman, PhD, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic products)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic products) Lauren Heim, MPH, Medline (Other Financial or Material Support, Conducted clinical trials and studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product)Stryker (Sage) (Other Financial or Material Support, Conducted clinical trials and studies in which participating hospitals and nursing homes received contributed antiseptic product)Xttrium (Other Financial or Material Support, Conducted clinical trials and studies in which participating hospitals and nursing homes received contributed antiseptic product) Syma Rashid, MD, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product)Stryker (Sage) (Other Financial or Material Support, Conducted clinical trials and studies in which participating hospitals and nursing homes received contributed antiseptic product)Xttrium (Other Financial or Material Support, Conducted clinical trials and studies in which participating hospitals and nursing homes received contributed antiseptic product) Taliser R. Avery, MS, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product) Kenneth Sands, MD, MPH, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product) Julia Moody, MS, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product) Micaela H. Coady, MS, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product) Kimberly N. Smith, MBA, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product) Brandon Carver, BA, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product) Caren Spencer-Smith, MS, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product) Russell Poland, PhD, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product) Jason Hickok, MBA, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product) Arjun Srinivasan, MD, Nothing to disclose John A. Jernigan, MD, MS, Nothing to disclose Jonathan B. Perlin, MD, PhD, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product) Richard Platt, MD, MSc, Medline (Research Grant or Support, Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product) Susan S. Huang, MD, MPH, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Stryker (Sage) (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Xttrium (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)
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Affiliation(s)
| | | | - Ken Kleinman
- University of Massachusetts, Amherst, Massachusetts
| | | | - Lauren Heim
- UC Irvine School of Medicine, IRVINE, California
| | - Syma Rashid
- UC Irvine School of Medicine, IRVINE, California
| | - Risa Rahm
- HCA Healthcare, Nashville, Tennessee
| | | | | | | | | | - Edward Rosen
- Harvard Pilgrim Healthcare Institute, Boston, Massachusetts
| | | | | | - Justin Vigeant
- Harvard Pilgrim Healthcare Institute, Boston, Massachusetts
| | | | | | | | | | - Micaela H Coady
- Harvard Pilgrim Health Care Institute, boston, Massachusetts
| | | | | | | | | | | | | | | | | | - Abinav Gowda
- Harvard Pilgrim Healthcare Institute, Boston, Massachusetts
| | - Robert Wolf
- Boston University School of Medicine, Boston, California
| | | | - Sujan Reddy
- Centers for Disease Control and Prevention, Atlanta, GA
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Huang SS, Septimus E, Kleinman K, Heim L, Moody J, Avery TR, McLean LE, Rashid S, Haffenreffer K, Shimelman L, Staub-Juergens W, Spencer-Smith C, Sljivo S, Rosen E, Poland R, Coady MH, Blanchard EJ, Reddish K, Hayden MK, Weinstein RA, Carver B, Smith KN, Hickok J, Lolans K, Khan N, Sturdevant SG, Reddy S, Jernigan JA, Jernigan JA, Sands K, Perlin JB, Platt R. 4. 137 Hospital Cluster-Randomized Trial of Mupirocin-Chlorhexidine vs Iodophor-Chlorhexidine for Universal Decolonization in Intensive Care Units (ICUs) (Mupirocin Iodophor Swap Out Trial). Open Forum Infect Dis 2021. [PMCID: PMC8644071 DOI: 10.1093/ofid/ofab466.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background ICU universal decolonization with daily chlorhexidine (CHG) baths plus mupirocin nasal decolonization reduces all-cause bloodstream infections (BSI) and MRSA clinical cultures. We assessed nasal iodophor, an antiseptic less susceptible to resistance, in place of mupirocin. Methods We conducted a cluster randomized non-inferiority trial in ICUs, comparing universal decolonization with: 1) Mupirocin-CHG: daily CHG baths and 5 days of twice daily nasal mupirocin, to 2) Iodophor-CHG: same regimen, substituting twice daily 10% povidone-iodine for mupirocin. All adult ICUs in a hospital were assigned to the same strategy. We compared each hospital’s outcomes during the 18-month intervention (Nov 2017-Apr 2019) to its own baseline (May 2015-Apr 2017), during which all hospitals used mupirocin-CHG. The primary outcome was ICU-attributable S. aureus clinical isolates. Secondary outcomes included ICU-attributable MRSA clinical isolates and all-cause BSI. As randomized and as treated analyses used unadjusted proportional hazards models assessing differences in outcomes between baseline and intervention periods across the two groups, accounting for clustering by hospital and patient. Results We randomized 137 hospitals with 233 ICUs in 18 states. There were 442,544 admissions in the baseline period and 349,262 in the intervention period. Median ICU length of stay was 4 days. ICU types included mixed medical surgical (56%), medical (9%), surgical (11%), cardiac (15%), and neurologic (9%). CHG adherence was similar in both arms (85%), but adherence was greater for mupirocin (90%) than iodophor (82%). Primary as-randomized results (Table, Figure) exceeded the non-inferiority margin in favor of mupirocin, for S. aureus clinical cultures (21% superiority, P< 0.001) and for MRSA clinical cultures (20% superiority, P< 0.001). The regimens had similar BSI hazards. Analyses of fully adherent patients are in progress. ![]()
Figure - Primary and Secondary Outcomes of Mupirocin Iodophor Swap Out Trial ![]()
Conclusion Universal iodophor-CHG was equivalent to mupirocin-CHG for ICU BSI prevention. Mupirocin-CHG was superior to iodophor-CHG for S. aureus and MRSA clinical isolates, potentially due to greater adherence to mupirocin. Disclosures Susan S. Huang, MD, MPH, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Stryker (Sage) (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Xttrium (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products) Edward Septimus, MD, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic products)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic products) Ken Kleinman, PhD, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic products)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic products) Lauren Heim, MPH, Medline (Other Financial or Material Support, Conducted clinical trials and studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product)Stryker (Sage) (Other Financial or Material Support, Conducted clinical trials and studies in which participating hospitals and nursing homes received contributed antiseptic product)Xttrium (Other Financial or Material Support, Conducted clinical trials and studies in which participating hospitals and nursing homes received contributed antiseptic product) Julia Moody, MS, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product) Taliser R. Avery, MS, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product) Syma Rashid, MD, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product)Stryker (Sage) (Other Financial or Material Support, Conducted clinical trials and studies in which participating hospitals and nursing homes received contributed antiseptic product)Xttrium (Other Financial or Material Support, Conducted clinical trials and studies in which participating hospitals and nursing homes received contributed antiseptic product) Katherine Haffenreffer, BS, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product) Lauren Shimelman, BA, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product) Caren Spencer-Smith, MS, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product) Selsebil Sljivo, MPH, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product) Ed Rosen, BS, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product) Russell Poland, PhD, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product) Micaela H. Coady, MS, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product) Eunice J. Blanchard, MSN RN, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product) Kimberly Reddish, DNP, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product) Brandon Carver, BA, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product) Kimberly N. Smith, MBA, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product) Jason Hickok, MBA, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product) Karen Lolans, BS, Medline (Research Grant or Support) Nadia Khan, BS, Medline (Research Grant or Support) John A. Jernigan, MD, MS, Nothing to disclose Kenneth Sands, MD, MPH, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product) Jonathan B. Perlin, MD, PhD, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product) Richard Platt, MD, MSc, Medline (Research Grant or Support, Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product)
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Affiliation(s)
| | | | - Ken Kleinman
- University of Massachusetts, Amherst, Massachusetts
| | - Lauren Heim
- UC Irvine School of Medicine, Irvine, California
| | | | | | | | - Syma Rashid
- UC Irvine School of Medicine, Irvine, California
| | | | - Lauren Shimelman
- Massachusetts Bay Transportation Authority, Boston, Massachusetts
| | | | | | - Selsebil Sljivo
- Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Ed Rosen
- Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | | | - Micaela H Coady
- Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | | | | | | | | | | | | | | | - Karen Lolans
- Rush University Medical Center, Chicago, Illinois
| | - Nadia Khan
- Emory University Rollins School of Public Health, Decatur, Georgia
| | | | - Sujan Reddy
- Centers for Disease Control and Prevention, Atlanta, GA
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6
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Gohil SK, Septimus E, Kleinman K, Varma N, Heim L, Rashid S, Rahm R, Cooper WS, McLean LE, Nickolay NG, Weinstein RA, Rosen E, Avery TR, Selsebil S, Vigeant J, Sands K, Cooper M, Burgess HL, Moody J, Coady MH, Rebecca GF, Smith KN, Carver B, Spencer-Smith C, Poland R, Hickok J, Sturdevant SG, Weiland A, Gowda A, Wolf R, Hayden MK, Reddy S, Neuhauser MM, Srinivasan A, Srinivasan A, Kubiak DW, Jernigan JA, Jernigan JA, Perlin JB, Platt R, Huang SS. 42. INSPIRE-ASP UTI Trial: A 59 Hospital Cluster Randomized Evaluation of INtelligent Stewardship Prompts to Improve Real-time Empiric Antibiotic Selection versus Routine Antibiotic Selection Practices for Patients with Urinary Tract Infection (UTI). Open Forum Infect Dis 2021. [PMCID: PMC8643895 DOI: 10.1093/ofid/ofab466.244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Up to 40% of hospitalized patients receive unnecessary or inappropriately broad antibiotics despite a low risk of multidrug-resistant organism (MDRO) infection. Empiric standard spectrum antibiotic use would reduce extended-spectrum (ES) antibiotic exposure and future resistance. We evaluated whether computerized prescriber order entry prompts providing patient-specific MDRO risk estimates could reduce ES antibiotic use compared to routine stewardship practices in patients hospitalized with urinary tract infection (UTI).
Methods
This 59-hospital cluster randomized trial compared: 1) INSPIRE prompts providing patient-specific MDRO UTI risk estimates at order entry and recommended standard spectrum antibiotics for risk < 10% versus 2) routine stewardship practices. Prompt used an absolute MDRO risk algorithm based on a 140 hospital data set. Trial population included adults treated with antibiotics for UTI in ED or non-ICU wards in first 3 days of admission (empiric days); prompt was triggered if ES antibiotics were ordered. Prescribers received feedback on prompt response. Trial periods: 18-month Baseline (Apr 2017–Sept 2018); 6-month Phase-in (Oct 2018–Mar 2019); 15-month Intervention (Apr 2019 – June 2020). Primary outcome was ES antibiotic days of therapy (ES-DOT) per empiric day; secondary outcomes were a) vancomycin and b) anti-pseudomonal DOT per empiric day. Unadjusted, as-randomized analyses used generalized linear mixed effects models to assess differences in ES-DOT rates between the intervention vs baseline period across arms (difference in differences), while clustering by patient and hospital.
Results
Results: We randomized 59 hospitals in 12 states, with 87,749 and 66,996 non-ICU UTI admissions in baseline and intervention periods, respectively. Intervention group had a a 21% reduction in ES-DOT compared to routine care. Vancomycin and anti-pseudomonal DOT were similarly reduced in the intervention group by 17% and 23%, respectively (Table).
Conclusion
Conclusion: INSPIRE order entry prompts providing real-time, patient-specific MDRO risk estimates with recommendation to use standard spectrum antibiotics in low risk patients significantly reduced empiric ES prescribing in adults admitted with UTI.
Disclosures
Shruti K. Gohil, MD, MPH, Medline (Other Financial or Material Support, Co-Investigator in studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Molnycke (Other Financial or Material Support, Co-Investigator in studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Stryker (Sage) (Other Financial or Material Support, Co-Investigator in studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products) Edward Septimus, MD, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic products)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic products) Ken Kleinman, PhD, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic products)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic products) Lauren Heim, MPH, Medline (Other Financial or Material Support, Conducted clinical trials and studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product)Stryker (Sage) (Other Financial or Material Support, Conducted clinical trials and studies in which participating hospitals and nursing homes received contributed antiseptic product)Xttrium (Other Financial or Material Support, Conducted clinical trials and studies in which participating hospitals and nursing homes received contributed antiseptic product) Syma Rashid, MD, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product)Stryker (Sage) (Other Financial or Material Support, Conducted clinical trials and studies in which participating hospitals and nursing homes received contributed antiseptic product)Xttrium (Other Financial or Material Support, Conducted clinical trials and studies in which participating hospitals and nursing homes received contributed antiseptic product) Taliser R. Avery, MS, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product) Kenneth Sands, MD, MPH, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product) Julia Moody, MS, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product) Kimberly N. Smith, MBA, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product) Brandon Carver, BA, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product) Caren Spencer-Smith, MS, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product) Russell Poland, PhD, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product) Jason Hickok, MBA, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product) Arjun Srinivasan, MD, Nothing to disclose John A. Jernigan, MD, MS, Nothing to disclose Jonathan B. Perlin, MD, PhD, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product) Richard Platt, MD, MSc, Medline (Research Grant or Support, Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product) Susan S. Huang, MD, MPH, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Stryker (Sage) (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Xttrium (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)
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Affiliation(s)
| | | | - Ken Kleinman
- University of Massachusetts, Amherst, Massachusetts
| | | | - Lauren Heim
- UC Irvine School of Medicine, IRVINE, California
| | - Syma Rashid
- UC Irvine School of Medicine, IRVINE, California
| | - Risa Rahm
- HCA Healthcare, Nashville, Tennessee
| | | | | | | | | | - Edward Rosen
- Harvard Pilgrim Healthcare Institute, Boston, Massachusetts
| | | | | | - Justin Vigeant
- Harvard Pilgrim Healthcare Institute, Boston, Massachusetts
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Abinav Gowda
- Harvard Pilgrim Healthcare Institute, Boston, Massachusetts
| | - Robert Wolf
- Boston University School of Medicine, Boston, California
| | | | - Sujan Reddy
- Centers for Disease Control and Prevention, Atlanta, GA
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7
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Yokoe DS, Avery TR, Platt R, Kleinman K, Huang SS. Ranking Hospitals Based on Colon Surgery and Abdominal Hysterectomy Surgical Site Infection Outcomes: Impact of Limiting Surveillance to the Operative Hospital. Clin Infect Dis 2019; 67:1096-1102. [PMID: 29566155 DOI: 10.1093/cid/ciy223] [Citation(s) in RCA: 9] [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] [Received: 11/14/2017] [Accepted: 03/15/2018] [Indexed: 11/14/2022] Open
Abstract
Background Hospital-specific surgical site infection (SSI) performance following colon surgery and abdominal hysterectomies can impact hospitals' relative rankings around quality metrics used to determine financial penalties. Current SSI surveillance largely focuses on SSI detected at the operative hospital. Methods We performed a retrospective cohort study to assess the impact on hospitals' relative SSI performance rankings when SSI detected at nonoperative hospitals are included. We used data from a California statewide hospital registry to assess for evidence of SSI following colon surgery or abdominal hysterectomies performed 1 March 2011 through 30 November 2013 using previously validated claims-based SSI surveillance methods. Risk-adjusted hospital-specific rankings based on SSI detected at operative hospitals versus any California hospital were generated. Results Among 60059 colon surgeries at 285 hospitals and 64918 abdominal hysterectomies at 270 hospitals, 5921 (9.9%) colon surgeries and 1481 (2.3%) abdominal hysterectomies received a diagnosis code for SSI within the 30 days following surgery. Operative hospital surveillance alone would have missed 7.2% of colon surgery and 13.4% of abdominal hysterectomy SSIs. The proportion of an individual hospital's SSIs detected during hospitalizations at other hospitals varied widely. Including nonoperative hospital SSIs resulted in improved relative ranking of 11 (3.9%) colon surgery and 13 (4.8%) hysterectomy hospitals so that they were no longer in the worst performing quartile, mainly among hospitals with relatively high surgical volumes. Conclusions Standard SSI surveillance that mainly focuses on infections detected at the operative hospital causes varying degrees of SSI underestimation, leading to inaccurate assignment or avoidance of financial penalties for approximately 1 in 11-16 hospitals.
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Affiliation(s)
- Deborah S Yokoe
- Division of Infectious Diseases, School of Medicine, University of California, San Francisco
| | - Taliser R Avery
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston
| | - Richard Platt
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston
| | - Ken Kleinman
- Department of Biostatistics and Epidemiology, School of Public Health and Health Sciences, University of Massachusetts Amherst
| | - Susan S Huang
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston.,Division of Infectious Diseases and Health Policy Research Institute, School of Medicine, University of California, Irvine
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8
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Huang SS, Septimus E, Kleinman K, Moody J, Hickok J, Heim L, Gombosev A, Avery TR, Haffenreffer K, Shimelman L, Hayden MK, Weinstein RA, Spencer-Smith C, Kaganov RE, Murphy MV, Forehand T, Lankiewicz J, Coady MH, Portillo L, Sarup-Patel J, Jernigan JA, Perlin JB, Platt R. Chlorhexidine versus routine bathing to prevent multidrug-resistant organisms and all-cause bloodstream infections in general medical and surgical units (ABATE Infection trial): a cluster-randomised trial. Lancet 2019; 393:1205-1215. [PMID: 30850112 PMCID: PMC6650266 DOI: 10.1016/s0140-6736(18)32593-5] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Revised: 08/28/2018] [Accepted: 10/11/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND Universal skin and nasal decolonisation reduces multidrug-resistant pathogens and bloodstream infections in intensive care units. The effect of universal decolonisation on pathogens and infections in non-critical-care units is unknown. The aim of the ABATE Infection trial was to evaluate the use of chlorhexidine bathing in non-critical-care units, with an intervention similar to one that was found to reduce multidrug-resistant organisms and bacteraemia in intensive care units. METHODS The ABATE Infection (active bathing to eliminate infection) trial was a cluster-randomised trial of 53 hospitals comparing routine bathing to decolonisation with universal chlorhexidine and targeted nasal mupirocin in non-critical-care units. The trial was done in hospitals affiliated with HCA Healthcare and consisted of a 12-month baseline period from March 1, 2013, to Feb 28, 2014, a 2-month phase-in period from April 1, 2014, to May 31, 2014, and a 21-month intervention period from June 1, 2014, to Feb 29, 2016. Hospitals were randomised and their participating non-critical-care units assigned to either routine care or daily chlorhexidine bathing for all patients plus mupirocin for known methicillin-resistant Staphylococcus aureus (MRSA) carriers. The primary outcome was MRSA or vancomycin-resistant enterococcus clinical cultures attributed to participating units, measured in the unadjusted, intention-to-treat population as the HR for the intervention period versus the baseline period in the decolonisation group versus the HR in the routine care group. Proportional hazards models assessed differences in outcome reductions across groups, accounting for clustering within hospitals. This trial is registered with ClinicalTrials.gov, number NCT02063867. FINDINGS There were 189 081 patients in the baseline period and 339 902 patients (156 889 patients in the routine care group and 183 013 patients in the decolonisation group) in the intervention period across 194 non-critical-care units in 53 hospitals. For the primary outcome of unit-attributable MRSA-positive or VRE-positive clinical cultures (figure 2), the HR for the intervention period versus the baseline period was 0·79 (0·73-0·87) in the decolonisation group versus 0·87 (95% CI 0·79-0·95) in the routine care group. No difference was seen in the relative HRs (p=0·17). There were 25 (<1%) adverse events, all involving chlorhexidine, among 183 013 patients in units assigned to chlorhexidine, and none were reported for mupirocin. INTERPRETATION Decolonisation with universal chlorhexidine bathing and targeted mupirocin for MRSA carriers did not significantly reduce multidrug-resistant organisms in non-critical-care patients. FUNDING National Institutes of Health.
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Affiliation(s)
- Susan S Huang
- Division of Infectious Diseases, University of California Irvine School of Medicine, Irvine, CA, USA.
| | - Edward Septimus
- Clinical Services Group, HCA Healthcare, Houston, TX, USA; Division of Infectious Diseases, Texas A&M College of Medicine, Houston, TX, USA; Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA, USA
| | - Ken Kleinman
- Department of Biostatistics and Epidemiology, School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, MA, USA
| | | | | | - Lauren Heim
- Division of Infectious Diseases, University of California Irvine School of Medicine, Irvine, CA, USA
| | - Adrijana Gombosev
- Division of Infectious Diseases, University of California Irvine School of Medicine, Irvine, CA, USA
| | - Taliser R Avery
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA, USA
| | - Katherine Haffenreffer
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA, USA
| | - Lauren Shimelman
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA, USA
| | - Mary K Hayden
- Division of Infectious Diseases, Rush Medical College, Chicago, IL, USA
| | - Robert A Weinstein
- Division of Infectious Diseases, Rush Medical College, Chicago, IL, USA; Department of Medicine, Cook County Health and Hospitals System, Chicago, IL, USA
| | | | - Rebecca E Kaganov
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA, USA
| | - Michael V Murphy
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA, USA
| | | | - Julie Lankiewicz
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA, USA
| | - Micaela H Coady
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA, USA
| | - Lena Portillo
- Division of Infectious Diseases, Rush Medical College, Chicago, IL, USA
| | - Jalpa Sarup-Patel
- Division of Infectious Diseases, Rush Medical College, Chicago, IL, USA
| | - John A Jernigan
- Office of HAI Prevention Research and Evaluation, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Richard Platt
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA, USA
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9
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Septimus E, Hickok J, Moody J, Kleinman K, Avery TR, Huang SS, Platt R, Perlin J. Closing the Translation Gap: Toolkit-based Implementation of Universal Decolonization in Adult Intensive Care Units Reduces Central Line-associated Bloodstream Infections in 95 Community Hospitals. Clin Infect Dis 2016; 63:172-7. [PMID: 27143669 DOI: 10.1093/cid/ciw282] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 04/03/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Challenges exist in implementing evidence-based strategies, reaching high compliance, and achieving desired outcomes. The rapid adoption of a publicly available toolkit featuring routine universal decolonization of intensive care unit (ICU) patients may affect catheter-related bloodstream infections. METHODS Implementation of universal decolonization-treatment of all ICU patients with chlorhexidine bathing and nasal mupirocin-used a prerelease version of a publicly available toolkit. Implementation in 136 adult ICUs in 95 acute care hospitals across the United States was supported by planning and deployment tactics coordinated by a central infection prevention team using toolkit resources, along with coaching calls and engagement of key stakeholders. Operational and process measures derived from a common electronic health record system provided real-time feedback about performance. Healthcare-associated central line-associated bloodstream infections (CLABSIs), using National Healthcare Safety Network surveillance definitions and comparing the preimplementation period of January 2011 through December 2012 to the postimplementation period of July 2013 through February 2014, were assessed via a Poisson generalized linear mixed model regression for CLABSI events. RESULTS Implementation of universal decolonization was completed within 6 months. The estimated rate of CLABSI decreased by 23.5% (95% confidence interval, 9.8%-35.1%; P = .001). There was no evidence of a trend over time in either the pre- or postimplementation period. Adjusting for seasonality and number of beds did not materially affect these results. CONCLUSIONS Dissemination of universal decolonization of ICU patients was accomplished quickly in a large community health system and was associated with declines in CLABSI consistent with published clinical trial findings.
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Affiliation(s)
- Edward Septimus
- Hospital Corporation of America, Nashville, Tennessee Texas A&M Health Science Center College of Medicine, Houston
| | - Jason Hickok
- Hospital Corporation of America, Nashville, Tennessee
| | - Julia Moody
- Hospital Corporation of America, Nashville, Tennessee
| | - Ken Kleinman
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Taliser R Avery
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Susan S Huang
- University of California, Irvine Health School of Medicine
| | - Richard Platt
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
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Datta R, King MK, Kim D, Nguyen C, Elkins K, Gombosev A, Avery TR, Meyers H, Cheung M, Huang SS. What Is Nosocomial? Large Variation in Hospital Choice of Numerators and Denominators Affects Rates of Hospital-Onset Methicillin-Resistant Staphylococcus aureus. Infect Control Hosp Epidemiol 2015; 33:1166-9. [DOI: 10.1086/668025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
We calculated hospital-onset methicillin-resistant Staphylococcus aureus (HO-MRSA) rates for Orange County, California, hospitals using survey and state data. Numerators were variably defined as HO-MRSA occurring more than 48 hours (37%), more than 2 days (30%), and more than 3 days (33%) postadmission. Survey-reported denominators differed from state-reported patient-days. Numerator and denominator choices substantially impacted HO-MRSA rates.
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Gombosev A, Fouad SE, Cui E, Cao C, Terpstra L, Avery TR, Kim D, Meyers H, Cheung M, Huang SS. Differences in hospital-associated multidrug-resistant organisms and Clostridium difficile rates using 2-day versus 3-day definitions. Infect Control Hosp Epidemiol 2014; 35:1417-20. [PMID: 25333439 DOI: 10.1086/678423] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
We surveyed infection prevention programs in 16 hospitals for hospital-associated methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci, extended-spectrum β-lactamase, and multidrug-resistant Acinetobacter acquisition, as well as hospital-associated MRSA bacteremia and Clostridium difficile infection based on defining events as occurring >2 days versus >3 days after admission. The former resulted in significantly higher median rates, ranging from 6.76% to 45.07% higher.
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Affiliation(s)
- Adrijana Gombosev
- Division of Infectious Diseases and Health Policy Research Institute, University of California-Irvine Health, Irvine, California
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Huang SS, Septimus E, Avery TR, Lee GM, Hickok J, Weinstein RA, Moody J, Hayden MK, Perlin JB, Platt R, Ray GT. Cost savings of universal decolonization to prevent intensive care unit infection: implications of the REDUCE MRSA trial. Infect Control Hosp Epidemiol 2014; 35 Suppl 3:S23-31. [PMID: 25222894 PMCID: PMC10920056 DOI: 10.1086/677819] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To estimate and compare the impact on healthcare costs of 3 alternative strategies for reducing bloodstream infections in the intensive care unit (ICU): methicillin-resistant Staphylococcus aureus (MRSA) nares screening and isolation, targeted decolonization (ie, screening, isolation, and decolonization of MRSA carriers or infections), and universal decolonization (ie, no screening and decolonization of all ICU patients). DESIGN Cost analysis using decision modeling. METHODS We developed a decision-analysis model to estimate the health care costs of targeted decolonization and universal decolonization strategies compared with a strategy of MRSA nares screening and isolation. Effectiveness estimates were derived from a recent randomized trial of the 3 strategies, and cost estimates were derived from the literature. RESULTS In the base case, universal decolonization was the dominant strategy and was estimated to have both lower intervention costs and lower total ICU costs than either screening and isolation or targeted decolonization. Compared with screening and isolation, universal decolonization was estimated to save $171,000 and prevent 9 additional bloodstream infections for every 1,000 ICU admissions. The dominance of universal decolonization persisted under a wide range of cost and effectiveness assumptions. CONCLUSIONS A strategy of universal decolonization for patients admitted to the ICU would both reduce bloodstream infections and likely reduce healthcare costs compared with strategies of MRSA nares screening and isolation or screening and isolation coupled with targeted decolonization.
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Affiliation(s)
- Susan S Huang
- Division of Infectious Diseases and Health Policy Research Institute, University of California Irvine School of Medicine, Orange, California
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Septimus EJ, Hayden MK, Kleinman K, Avery TR, Moody J, Weinstein RA, Hickok J, Lankiewicz J, Gombosev A, Haffenreffer K, Kaganov RE, Jernigan JA, Perlin JB, Platt R, Huang SS. Does chlorhexidine bathing in adult intensive care units reduce blood culture contamination? A pragmatic cluster-randomized trial. Infect Control Hosp Epidemiol 2014; 35 Suppl 3:S17-22. [PMID: 25222893 PMCID: PMC10860380 DOI: 10.1086/677822] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To determine rates of blood culture contamination comparing 3 strategies to prevent intensive care unit (ICU) infections: screening and isolation, targeted decolonization, and universal decolonization. DESIGN Pragmatic cluster-randomized trial. SETTING Forty-three hospitals with 74 ICUs; 42 of 43 were community hospitals. PATIENTS Patients admitted to adult ICUs from July 1, 2009, to September 30, 2011. METHODS After a 6-month baseline period, hospitals were randomly assigned to 1 of 3 strategies, with all participating adult ICUs in a given hospital assigned to the same strategy. Arm 1 implemented methicillin-resistant Staphylococcus aureus (MRSA) nares screening and isolation, arm 2 targeted decolonization (screening, isolation, and decolonization of MRSA carriers), and arm 3 conducted no screening but universal decolonization of all patients with mupirocin and chlorhexidine (CHG) bathing. Blood culture contamination rates in the intervention period were compared to the baseline period across all 3 arms. RESULTS During the 6-month baseline period, 7,926 blood cultures were collected from 3,399 unique patients: 1,099 sets in arm 1, 928 in arm 2, and 1,372 in arm 3. During the 18-month intervention period, 22,761 blood cultures were collected from 9,878 unique patients: 3,055 sets in arm 1, 3,213 in arm 2, and 3,610 in arm 3. Among all individual draws, for arms 1, 2, and 3, the contamination rates were 4.1%, 3.9%, and 3.8% for the baseline period and 3.3%, 3.2%, and 2.4% for the intervention period, respectively. When we evaluated sets of blood cultures rather than individual draws, the contamination rate in arm 1 (screening and isolation) was 9.8% (N = 108 sets) in the baseline period and 7.5% (N = 228) in the intervention period. For arm 2 (targeted decolonization), the baseline rate was 8.4% (N = 78) compared to 7.5% (N = 241) in the intervention period. Arm 3 (universal decolonization) had the greatest decrease in contamination rate, with a decrease from 8.7% (N = 119) contaminated blood cultures during the baseline period to 5.1% (N = 184) during the intervention period. Logistic regression models demonstrated a significant difference across the arms when comparing the reduction in contamination between baseline and intervention periods in both unadjusted (P = .02) and adjusted (P = .02) analyses. Arm 3 resulted in the greatest reduction in blood culture contamination rates, with an unadjusted odds ratio (OR) of 0.56 (95% confidence interval [CI], 0.044-0.71) and an adjusted OR of 0.55 (95% CI, 0.43-0.71). CONCLUSION In this large cluster-randomized trial, we demonstrated that universal decolonization with CHG bathing resulted in a significant reduction in blood culture contamination.
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Bartsch SM, Huang SS, Wong KF, Avery TR, Lee BY. The spread and control of norovirus outbreaks among hospitals in a region: a simulation model. Open Forum Infect Dis 2014; 1:ofu030. [PMID: 25734110 PMCID: PMC4281820 DOI: 10.1093/ofid/ofu030] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Accepted: 05/11/2014] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Because hospitals in a region are connected via patient sharing, a norovirus outbreak in one hospital may spread to others. METHODS We utilized our Regional Healthcare Ecosystem Analyst software to generate an agent-based model of all the acute care facilities in Orange County (OC), California and simulated various norovirus outbreaks in different locations, both with and without contact precautions. RESULTS At the lower end of norovirus reproductive rate (R0) estimates (1.64), an outbreak tended to remain confined to the originating hospital (≤6.1% probability of spread). However, at the higher end of R0 (3.74), an outbreak spread 4.1%-17.5% of the time to almost all other OC hospitals within 30 days, regardless of the originating hospital. Implementing contact precautions for all symptomatic cases reduced the probability of spread to other hospitals within 30 days and the total number of cases countywide, but not the number of other hospitals seeing norovirus cases. CONCLUSIONS A single norovirus outbreak can continue to percolate throughout a system of different hospitals for several months and appear as a series of unrelated outbreaks, highlighting the need for hospitals within a region to more aggressively and cooperatively track and control an initial outbreak.
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Affiliation(s)
- Sarah M. Bartsch
- Public Health Computational and Operations Research (PHICOR), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Industrial Engineering
| | - Susan S. Huang
- University of California School of Medicine, Irvine, California
| | - Kim F. Wong
- Center for Simulation and Modeling, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Taliser R. Avery
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Bruce Y. Lee
- Public Health Computational and Operations Research (PHICOR), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Yokoe DS, Avery TR, Platt R, Huang SS. Reporting surgical site infections following total hip and knee arthroplasty: impact of limiting surveillance to the operative hospital. Clin Infect Dis 2013; 57:1282-8. [PMID: 23912846 DOI: 10.1093/cid/cit516] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [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: 01/26/2023] Open
Abstract
BACKGROUND Public reporting of surgical site infections (SSIs) by hospitals is largely limited to infections detected during surgical hospitalizations or readmissions to the same facility. SSI rates may be underestimated if patients with SSIs are readmitted to other hospitals. We assessed the impact of readmissions to other facilities on hospitals' SSI rates following primary total hip arthroplasty (THA) or total knee arthroplasty (TKA). METHODS This was a retrospective cohort study of all patients who underwent primary THA or TKA at California hospitals between 1 January 2006 and 31 December 2009. SSIs were identified using ICD-9-CM diagnosis codes predictive of SSI assigned at any California hospital within 365 days of surgery using a statewide repository of hospital data that allowed tracking of patients between facilities. We used statewide data to estimate the fraction of each hospital's THA and TKA SSIs identified at the operative hospital versus other hospitals. RESULTS A total of 91 121 THA and 121 640 TKA procedures were identified. Based on diagnosis codes, SSIs developed following 2214 (2.3%) THAs and 2465 (2.0%) TKAs. Seventeen percent of SSIs would have been missed by operative hospital surveillance alone. The proportion of hospitals' SSIs detected at nonoperative hospitals ranged from 0% to 100%. Including SSIs detected at nonoperative hospitals resulted in better relative ranking for 61% of THA hospitals and 61% of TKA hospitals. CONCLUSIONS Limiting SSI surveillance to the operative hospital caused varying degrees of SSI underestimation and substantially impacted hospitals' relative rankings, suggesting that alternative methods for comprehensive postdischarge surveillance are needed for accurate benchmarking.
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Affiliation(s)
- Deborah S Yokoe
- Infectious Diseases Division, Brigham and Women's Hospital and Harvard Medical School
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16
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Lee BY, Yilmaz SL, Wong KF, Bartsch SM, Eubank S, Song Y, Avery TR, Christie R, Brown ST, Epstein JM, Parker JI, Huang SS. Modeling the regional spread and control of vancomycin-resistant enterococci. Am J Infect Control 2013; 41:668-73. [PMID: 23896284 DOI: 10.1016/j.ajic.2013.01.013] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [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: 09/27/2012] [Revised: 01/03/2013] [Accepted: 01/04/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Because patients can remain colonized with vancomycin-resistant enterococci (VRE) for long periods of time, VRE may spread from one health care facility to another. METHODS Using the Regional Healthcare Ecosystem Analyst, an agent-based model of patient flow among all Orange County, California, hospitals and communities, we quantified the degree and speed at which changes in VRE colonization prevalence in a hospital may affect prevalence in other Orange County hospitals. RESULTS A sustained 10% increase in VRE colonization prevalence in any 1 hospital caused a 2.8% (none to 62%) average relative increase in VRE prevalence in all other hospitals. Effects took from 1.5 to >10 years to fully manifest. Larger hospitals tended to have greater affect on other hospitals. CONCLUSIONS When monitoring and controlling VRE, decision makers may want to account for regional effects. Knowing a hospital's connections with other health care facilities via patient sharing can help determine which hospitals to include in a surveillance or control program.
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Affiliation(s)
- Bruce Y Lee
- Public Health Computational and Operations Research, University of Pittsburgh, Pittsburgh, PA 15213, USA.
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17
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Huang SS, Septimus E, Kleinman K, Moody J, Hickok J, Avery TR, Lankiewicz J, Gombosev A, Terpstra L, Hartford F, Hayden MK, Jernigan JA, Weinstein RA, Fraser VJ, Haffenreffer K, Cui E, Kaganov RE, Lolans K, Perlin JB, Platt R. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med 2013; 368:2255-65. [PMID: 23718152 PMCID: PMC10853913 DOI: 10.1056/nejmoa1207290] [Citation(s) in RCA: 511] [Impact Index Per Article: 46.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Both targeted decolonization and universal decolonization of patients in intensive care units (ICUs) are candidate strategies to prevent health care-associated infections, particularly those caused by methicillin-resistant Staphylococcus aureus (MRSA). METHODS We conducted a pragmatic, cluster-randomized trial. Hospitals were randomly assigned to one of three strategies, with all adult ICUs in a given hospital assigned to the same strategy. Group 1 implemented MRSA screening and isolation; group 2, targeted decolonization (i.e., screening, isolation, and decolonization of MRSA carriers); and group 3, universal decolonization (i.e., no screening, and decolonization of all patients). Proportional-hazards models were used to assess differences in infection reductions across the study groups, with clustering according to hospital. RESULTS A total of 43 hospitals (including 74 ICUs and 74,256 patients during the intervention period) underwent randomization. In the intervention period versus the baseline period, modeled hazard ratios for MRSA clinical isolates were 0.92 for screening and isolation (crude rate, 3.2 vs. 3.4 isolates per 1000 days), 0.75 for targeted decolonization (3.2 vs. 4.3 isolates per 1000 days), and 0.63 for universal decolonization (2.1 vs. 3.4 isolates per 1000 days) (P=0.01 for test of all groups being equal). In the intervention versus baseline periods, hazard ratios for bloodstream infection with any pathogen in the three groups were 0.99 (crude rate, 4.1 vs. 4.2 infections per 1000 days), 0.78 (3.7 vs. 4.8 infections per 1000 days), and 0.56 (3.6 vs. 6.1 infections per 1000 days), respectively (P<0.001 for test of all groups being equal). Universal decolonization resulted in a significantly greater reduction in the rate of all bloodstream infections than either targeted decolonization or screening and isolation. One bloodstream infection was prevented per 54 patients who underwent decolonization. The reductions in rates of MRSA bloodstream infection were similar to those of all bloodstream infections, but the difference was not significant. Adverse events, which occurred in 7 patients, were mild and related to chlorhexidine. CONCLUSIONS In routine ICU practice, universal decolonization was more effective than targeted decolonization or screening and isolation in reducing rates of MRSA clinical isolates and bloodstream infection from any pathogen. (Funded by the Agency for Healthcare Research and the Centers for Disease Control and Prevention; REDUCE MRSA ClinicalTrials.gov number, NCT00980980).
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Affiliation(s)
- Susan S Huang
- University of California Irvine School of Medicine, Orange, CA 92868, USA.
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18
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Lee BY, Wong KF, Bartsch SM, Yilmaz SL, Avery TR, Brown ST, Song Y, Singh A, Kim DS, Huang SS. The Regional Healthcare Ecosystem Analyst (RHEA): a simulation modeling tool to assist infectious disease control in a health system. J Am Med Inform Assoc 2013; 20:e139-46. [PMID: 23571848 DOI: 10.1136/amiajnl-2012-001107] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE As healthcare systems continue to expand and interconnect with each other through patient sharing, administrators, policy makers, infection control specialists, and other decision makers may have to take account of the entire healthcare 'ecosystem' in infection control. MATERIALS AND METHODS We developed a software tool, the Regional Healthcare Ecosystem Analyst (RHEA), that can accept user-inputted data to rapidly create a detailed agent-based simulation model (ABM) of the healthcare ecosystem (ie, all healthcare facilities, their adjoining community, and patient flow among the facilities) of any region to better understand the spread and control of infectious diseases. RESULTS To demonstrate RHEA's capabilities, we fed extensive data from Orange County, California, USA, into RHEA to create an ABM of a healthcare ecosystem and simulate the spread and control of methicillin-resistant Staphylococcus aureus. Various experiments explored the effects of changing different parameters (eg, degree of transmission, length of stay, and bed capacity). DISCUSSION Our model emphasizes how individual healthcare facilities are components of integrated and dynamic networks connected via patient movement and how occurrences in one healthcare facility may affect many other healthcare facilities. CONCLUSIONS A decision maker can utilize RHEA to generate a detailed ABM of any healthcare system of interest, which in turn can serve as a virtual laboratory to test different policies and interventions.
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Affiliation(s)
- Bruce Y Lee
- Public Health Computational and Operations Research, University of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA.
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Kulldorff M, Dashevsky I, Avery TR, Chan AK, Davis RL, Graham D, Platt R, Andrade SE, Boudreau D, Gunter MJ, Herrinton LJ, Pawloski PA, Raebel MA, Roblin D, Brown JS. Drug safety data mining with a tree-based scan statistic. Pharmacoepidemiol Drug Saf 2013; 22:517-23. [DOI: 10.1002/pds.3423] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2012] [Revised: 01/08/2013] [Accepted: 01/28/2013] [Indexed: 11/12/2022]
Affiliation(s)
- Martin Kulldorff
- Department of Population Medicine; Harvard Medical School and Harvard Pilgrim Health Care Institute; Boston MA USA
- The HMO Research Network Center for Education and Research in Therapeutics
| | - Inna Dashevsky
- Department of Population Medicine; Harvard Medical School and Harvard Pilgrim Health Care Institute; Boston MA USA
| | - Taliser R. Avery
- Department of Population Medicine; Harvard Medical School and Harvard Pilgrim Health Care Institute; Boston MA USA
| | - Arnold K. Chan
- Harvard School of Public Health; Boston MA USA
- i3 Drug Safety; Waltham MA USA
| | | | - David Graham
- Office of Drug Safety; Food and Drug Administration; Rockville MD USA
| | - Richard Platt
- Department of Population Medicine; Harvard Medical School and Harvard Pilgrim Health Care Institute; Boston MA USA
- The HMO Research Network Center for Education and Research in Therapeutics
| | - Susan E Andrade
- The HMO Research Network Center for Education and Research in Therapeutics
- Meyers Primary Care Institute; University of Massachusetts Medical School, the Fallon Foundation, and Fallon Community Health Plan; Worcester MA USA
| | - Denise Boudreau
- The HMO Research Network Center for Education and Research in Therapeutics
- Group Health Research Institute; Seattle WA USA
| | - Margaret J. Gunter
- The HMO Research Network Center for Education and Research in Therapeutics
- Lovelace Clinic Foundation; Albuquerque NM USA
| | - Lisa J. Herrinton
- The HMO Research Network Center for Education and Research in Therapeutics
- Kaiser Permanente Northern California; Oakland CA USA
| | - Pamala A. Pawloski
- The HMO Research Network Center for Education and Research in Therapeutics
- HealthPartners Institute for Research and Education; Minneapolis MN USA
| | - Marsha A. Raebel
- The HMO Research Network Center for Education and Research in Therapeutics
- Kaiser Permanente Colorado; Denver CO USA
| | - Douglas Roblin
- The HMO Research Network Center for Education and Research in Therapeutics
- Kaiser Permanente Georgia; Atlanta GA USA
| | - Jeffrey S. Brown
- Department of Population Medicine; Harvard Medical School and Harvard Pilgrim Health Care Institute; Boston MA USA
- The HMO Research Network Center for Education and Research in Therapeutics
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Lee BY, Bartsch SM, Wong KF, Yilmaz SL, Avery TR, Singh A, Song Y, Kim DS, Brown ST, Potter MA, Platt R, Huang SS. Simulation shows hospitals that cooperate on infection control obtain better results than hospitals acting alone. Health Aff (Millwood) 2013; 31:2295-303. [PMID: 23048111 DOI: 10.1377/hlthaff.2011.0992] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Efforts to control life-threatening infections, such as with methicillin-resistant Staphylococcus aureus (MRSA), can be complicated when patients are transferred from one hospital to another. Using a detailed computer simulation model of all hospitals in Orange County, California, we explored the effects when combinations of hospitals tested all patients at admission for MRSA and adopted procedures to limit transmission among patients who tested positive. Called "contact isolation," these procedures specify precautions for health care workers interacting with an infected patient, such as wearing gloves and gowns. Our simulation demonstrated that each hospital's decision to test for MRSA and implement contact isolation procedures could affect the MRSA prevalence in all other hospitals. Thus, our study makes the case that further cooperation among hospitals--which is already reflected in a few limited collaborative infection control efforts under way--could help individual hospitals achieve better infection control than they could achieve on their own.
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Affiliation(s)
- Bruce Y Lee
- University of Pittsburgh, Pennsylvania, USA.
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21
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Avery TR, Kulldorff M, Vilk Y, Li L, Cheetham TC, Dublin S, Davis RL, Liu L, Herrinton L, Brown JS. Near real-time adverse drug reaction surveillance within population-based health networks: methodology considerations for data accrual. Pharmacoepidemiol Drug Saf 2013; 22:488-95. [PMID: 23401239 DOI: 10.1002/pds.3412] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Revised: 11/28/2012] [Accepted: 01/02/2013] [Indexed: 01/26/2023]
Abstract
PURPOSE This study describes practical considerations for implementation of near real-time medical product safety surveillance in a distributed health data network. METHODS We conducted pilot active safety surveillance comparing generic divalproex sodium to historical branded product at four health plans from April to October 2009. Outcomes reported are all-cause emergency room visits and fractures. One retrospective data extract was completed (January 2002-June 2008), followed by seven prospective monthly extracts (January 2008-November 2009). To evaluate delays in claims processing, we used three analytic approaches: near real-time sequential analysis, sequential analysis with 1.5 month delay, and nonsequential (using final retrospective data). Sequential analyses used the maximized sequential probability ratio test. Procedural and logistical barriers to active surveillance were documented. RESULTS We identified 6586 new users of generic divalproex sodium and 43,960 new users of the branded product. Quality control methods identified 16 extract errors, which were corrected. Near real-time extracts captured 87.5% of emergency room visits and 50.0% of fractures, which improved to 98.3% and 68.7% respectively with 1.5 month delay. We did not identify signals for either outcome regardless of extract timeframe, and slight differences in the test statistic and relative risk estimates were found. CONCLUSIONS Near real-time sequential safety surveillance is feasible, but several barriers warrant attention. Data quality review of each data extract was necessary. Although signal detection was not affected by delay in analysis, when using a historical control group differential accrual between exposure and outcomes may theoretically bias near real-time risk estimates towards the null, causing failure to detect a signal.
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Affiliation(s)
- Taliser R Avery
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA.
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22
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Lee BY, Singh A, Bartsch SM, Wong KF, Kim DS, Avery TR, Brown ST, Murphy CR, Yilmaz SL, Huang SS. The potential regional impact of contact precaution use in nursing homes to control methicillin-resistant Staphylococcus aureus. Infect Control Hosp Epidemiol 2012; 34:151-60. [PMID: 23295561 DOI: 10.1086/669091] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Implementation of contact precautions in nursing homes to prevent methicillin-resistant Staphylococcus aureus (MRSA) transmission could cost time and effort and may have wide-ranging effects throughout multiple health facilities. Computational modeling could forecast the potential effects and guide policy making. DESIGN Our multihospital computational agent-based model, Regional Healthcare Ecosystem Analyst (RHEA). SETTING All hospitals and nursing homes in Orange County, California. METHODS Our simulation model compared the following 3 contact precaution strategies: (1) no contact precautions applied to any nursing home residents, (2) contact precautions applied to those with clinically apparent MRSA infections, and (3) contact precautions applied to all known MRSA carriers as determined by MRSA screening performed by hospitals. RESULTS Our model demonstrated that contact precautions for patients with clinically apparent MRSA infections in nursing homes resulted in a median 0.4% (range, 0%-1.6%) relative decrease in MRSA prevalence in nursing homes (with 50% adherence) but had no effect on hospital MRSA prevalence, even 5 years after initiation. Implementation of contact precautions (with 50% adherence) in nursing homes for all known MRSA carriers was associated with a median 14.2% (range, 2.1%-21.8%) relative decrease in MRSA prevalence in nursing homes and a 2.3% decrease (range, 0%-7.1%) in hospitals 1 year after implementation. Benefits accrued over time and increased with increasing compliance. CONCLUSIONS Our modeling study demonstrated the substantial benefits of extending contact precautions in nursing homes from just those residents with clinically apparent infection to all MRSA carriers, which suggests the benefits of hospitals and nursing homes sharing and coordinating information on MRSA surveillance and carriage status.
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Affiliation(s)
- Bruce Y Lee
- University of Pittsburgh, Pittsburgh, PA 15213, USA.
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Avery TR, Kleinman KP, Klompas M, Aschengrau A, Huang SS. Reply to Moehring et al. Infect Control Hosp Epidemiol 2012. [DOI: 10.1086/666637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Lee BY, Song Y, Bartsch SM, Kim DS, Singh A, Avery TR, Brown ST, Yilmaz SL, Wong KF, Potter MA, Burke DS, Platt R, Huang SS. Long-term care facilities: important participants of the acute care facility social network? PLoS One 2011; 6:e29342. [PMID: 22216255 PMCID: PMC3246493 DOI: 10.1371/journal.pone.0029342] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Accepted: 11/25/2011] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Acute care facilities are connected via patient sharing, forming a network. However, patient sharing extends beyond this immediate network to include sharing with long-term care facilities. The extent of long-term care facility patient sharing on the acute care facility network is unknown. The objective of this study was to characterize and determine the extent and pattern of patient transfers to, from, and between long-term care facilities on the network of acute care facilities in a large metropolitan county. METHODS/PRINCIPAL FINDINGS We applied social network constructs principles, measures, and frameworks to all 2007 annual adult and pediatric patient transfers among the healthcare facilities in Orange County, California, using data from surveys and several datasets. We evaluated general network and centrality measures as well as individual ego measures and further constructed sociograms. Our results show that over the course of a year, 66 of 72 long-term care facilities directly sent and 67 directly received patients from other long-term care facilities. Long-term care facilities added 1,524 ties between the acute care facilities when ties represented at least one patient transfer. Geodesic distance did not closely correlate with the geographic distance among facilities. CONCLUSIONS/SIGNIFICANCE This study demonstrates the extent to which long-term care facilities are connected to the acute care facility patient sharing network. Many long-term care facilities were connected by patient transfers and further added many connections to the acute care facility network. This suggests that policy-makers and health officials should account for patient sharing with and among long-term care facilities as well as those among acute care facilities when evaluating policies and interventions.
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Affiliation(s)
- Bruce Y Lee
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
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Avery TR, Kleinman KP, Klompas M, Aschengrau A, Huang SS. Inclusion of 30-day postdischarge detection triples the incidence of hospital-onset methicillin-resistant Staphylococcus aureus. Infect Control Hosp Epidemiol 2011; 33:114-21. [PMID: 22227979 DOI: 10.1086/663714] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Hospitalized patients are at increased risk for acquisition of methicillin-resistant Staphylococcus aureus (MRSA). As hospital length of stay shortens, hospital-acquired MRSA events may be more likely to be detected after discharge. OBJECTIVE We assessed the impact of attributing MRSA cases discovered within 30 days after discharge to the most recent hospitalization and identified patient characteristics associated with MRSA detection after discharge. DESIGN Retrospective cohort study. SETTING Twenty-seven acute care hospitals in Orange County, California. PARTICIPANTS Adult acute care admissions (2002-2007). METHODS Using a countywide hospital data set containing diagnostic codes with present-on-admission (POA) indicators, we identified the first admission with a MRSA code for each patient. This incident MRSA admission was defined as predischarge-detected (pre-DD) hospital-onset MRSA (HO-MRSA) when MRSA was not POA. If MRSA was POA and a prior admission occurred within 30 days, this prior admission was assigned postdischarge-detected (post-DD) HO-MRSA. We evaluated the impact of including post-DD HO-MRSA in the calculation of hospital HO-MRSA incidence using signed-rank tests and reviewed changes in hospital rankings. We conducted multivariate comparisons of patient characteristics of pre-DD versus post-DD HO-MRSA patients. RESULTS Among 1,217,253 at-risk hospitalizations, the inclusion of post-DD HO-MRSA tripled the median hospital HO-MRSA incidence, from 12.2 to 35.7 cases per 10,000 at-risk admissions (P < .0001). Hospital ranking changed substantially when including post-DD HO-MRSA. Patients with shorter stays were more likely to have post-DD MRSA. CONCLUSIONS On the basis of administrative claims data, the inclusion of post-DD HO-MRSA significantly increased the estimated HO-MRSA incidence and altered hospital rankings. This finding underscores the limitations of single-facility data when deriving HO-MRSA incidence and rank.
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Affiliation(s)
- Taliser R Avery
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts 02215, USA.
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Murphy CR, Avery TR, Dubberke ER, Huang SS. Frequent hospital readmissions for Clostridium difficile infection and the impact on estimates of hospital-associated C. difficile burden. Infect Control Hosp Epidemiol 2011; 33:20-8. [PMID: 22173518 DOI: 10.1086/663209] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Clostridium difficile infection (CDI) is associated with hospitalization and may cause readmission following admission for any reason. We aimed to measure the incidence of readmissions due to CDI. DESIGN Retrospective cohort study. PATIENTS Adult inpatients in Orange County, California, who presented with new-onset CDI within 12 weeks of discharge. METHODS We assessed mandatory 2000-2007 hospital discharge data for trends in hospital-associated CDI (HA-CDI) incidence, with and without inclusion of postdischarge CDI (PD-CDI) events resulting in rehospitalization within 12 weeks of discharge. We measured the effect of including PD-CDI events on hospital-specific CDI incidence, a mandatory reporting measure in California, and on relative hospital ranks by CDI incidence. RESULTS From 2000 to 2007, countywide hospital-onset CDI (HO-CDI) incidence increased from 15 per 10,000 to 22 per 10,000 admissions. When including PD-CDI events, HA-CDI incidence doubled (29 per 10,000 in 2000 and 52 per 10,000 in 2007). Overall, including PD-CDI events resulted in significantly higher hospital-specific CDI incidence, although hospitals had disproportionate amounts of HA-CDI occurring postdischarge. This resulted in substantial shifts in some hospitals' rankings by CDI incidence. In multivariate models, both HO and PD-CDI were associated with increasing age, higher length of stay, and select comorbidities. Race and Hispanic ethnicity were predictive of PD-CDI but not HO-CDI. CONCLUSIONS PD-CDI events associated with rehospitalization are increasingly common. The majority of HA-CDI cases may be occurring postdischarge, raising important questions about both accurate reporting and effective prevention strategies. Some risk factors for PD-CDI may be different than those for HO-CDI, allowing additional identification of high-risk groups before discharge.
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Affiliation(s)
- Courtney R Murphy
- Division of Infectious Diseases and Health Policy Research Institute, University of California Irvine School of Medicine, Irvine, California, USA.
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Lee BY, McGlone SM, Wong KF, Yilmaz SL, Avery TR, Song Y, Christie R, Eubank S, Brown ST, Epstein JM, Parker JI, Burke DS, Platt R, Huang SS. Modeling the spread of methicillin-resistant Staphylococcus aureus (MRSA) outbreaks throughout the hospitals in Orange County, California. Infect Control Hosp Epidemiol 2011; 32:562-72. [PMID: 21558768 DOI: 10.1086/660014] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Since hospitals in a region often share patients, an outbreak of methicillin-resistant Staphylococcus aureus (MRSA) infection in one hospital could affect other hospitals. METHODS Using extensive data collected from Orange County (OC), California, we developed a detailed agent-based model to represent patient movement among all OC hospitals. Experiments simulated MRSA outbreaks in various wards, institutions, and regions. Sensitivity analysis varied lengths of stay, intraward transmission coefficients (β), MRSA loss rate, probability of patient transfer or readmission, and time to readmission. RESULTS Each simulated outbreak eventually affected all of the hospitals in the network, with effects depending on the outbreak size and location. Increasing MRSA prevalence at a single hospital (from 5% to 15%) resulted in a 2.9% average increase in relative prevalence at all other hospitals (ranging from no effect to 46.4%). Single-hospital intensive care unit outbreaks (modeled increase from 5% to 15%) caused a 1.4% average relative increase in all other OC hospitals (ranging from no effect to 12.7%). CONCLUSION MRSA outbreaks may rarely be confined to a single hospital but instead may affect all of the hospitals in a region. This suggests that prevention and control strategies and policies should account for the interconnectedness of health care facilities.
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Affiliation(s)
- Bruce Y Lee
- University of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA.
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Huang SS, Avery TR, Song Y, Elkins KR, Nguyen CC, Nutter SK, Nafday AA, Condon CJ, Chang MT, Chrest D, Boos J, Bobashev G, Wheaton W, Frank SA, Platt R, Lipsitch M, Bush RM, Eubank S, Burke DS, Lee BY. Quantifying interhospital patient sharing as a mechanism for infectious disease spread. Infect Control Hosp Epidemiol 2011; 31:1160-9. [PMID: 20874503 DOI: 10.1086/656747] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Assessments of infectious disease spread in hospitals seldom account for interfacility patient sharing. This is particularly important for pathogens with prolonged incubation periods or carrier states. METHODS We quantified patient sharing among all 32 hospitals in Orange County (OC), California, using hospital discharge data. Same-day transfers between hospitals were considered "direct" transfers, and events in which patients were shared between hospitals after an intervening stay at home or elsewhere were considered "indirect" patient-sharing events. We assessed the frequency of readmissions to another OC hospital within various time points from discharge and examined interhospital sharing of patients with Clostridium difficile infection. RESULTS In 2005, OC hospitals had 319,918 admissions. Twenty-nine percent of patients were admitted at least twice, with a median interval between discharge and readmission of 53 days. Of the patients with 2 or more admissions, 75% were admitted to more than 1 hospital. Ninety-four percent of interhospital patient sharing occurred indirectly. When we used 10 shared patients as a measure of potential interhospital exposure, 6 (19%) of 32 hospitals "exposed" more than 50% of all OC hospitals within 6 months, and 17 (53%) exposed more than 50% within 12 months. Hospitals shared 1 or more patient with a median of 28 other hospitals. When we evaluated patients with C. difficile infection, 25% were readmitted within 12 weeks; 41% were readmitted to different hospitals, and less than 30% of these readmissions were direct transfers. CONCLUSIONS In a large metropolitan county, interhospital patient sharing was a potential avenue for transmission of infectious agents. Indirect sharing with an intervening stay at home or elsewhere composed the bulk of potential exposures and occurred unbeknownst to hospitals.
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Affiliation(s)
- Susan S Huang
- Division of Infectious Diseases and Health Policy Research Institute, University of California Irvine, Irvine, California, USA.
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Lee BY, McGlone SM, Song Y, Avery TR, Eubank S, Chang CC, Bailey RR, Wagener DK, Burke DS, Platt R, Huang SS. Social network analysis of patient sharing among hospitals in Orange County, California. Am J Public Health 2011; 101:707-13. [PMID: 21330578 DOI: 10.2105/ajph.2010.202754] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [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
OBJECTIVES We applied social network analyses to determine how hospitals within Orange County, California, are interconnected by patient sharing, a system which may have numerous public health implications. METHODS Our analyses considered 2 general patient-sharing networks: uninterrupted patient sharing (UPS; i.e., direct interhospital transfers) and total patient sharing (TPS; i.e., all interhospital patient sharing, including patients with intervening nonhospital stays). We considered these networks at 3 thresholds of patient sharing: at least 1, at least 10, and at least 100 patients shared. RESULTS Geographically proximate hospitals were somewhat more likely to share patients, but many hospitals shared patients with distant hospitals. Number of patient admissions and percentage of cancer patients were associated with greater connectivity across the system. The TPS network revealed numerous connections not seen in the UPS network, meaning that direct transfers only accounted for a fraction of total patient sharing. CONCLUSIONS Our analysis demonstrated that Orange County's 32 hospitals were highly and heterogeneously interconnected by patient sharing. Different hospital populations had different levels of influence over the patient-sharing network.
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Affiliation(s)
- Bruce Y Lee
- Public Health Computational and Operations Research Group, Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA.
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