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We performed an intervention evaluating the impact of an electronic hard-stop clinical decision support tool on repeat Clostridioides difficile (CD) toxin enzyme immunoassay (T-EIA) testing. The CD testing rate and number of admissions with repeat tests decreased significantly postintervention (P < .01 for both); the percentage of positive tests was unchanged (P = .27).
Clinical Enterobacteriacae isolates with a colistin minimum inhibitory concentration (MIC) ≥4 mg/L from a United States hospital were screened for the mcr-1 gene using real-time polymerase chain reaction (RT-PCR) and confirmed by whole-genome sequencing. Four colistin-resistant Escherichia coli isolates contained mcr-1. Two isolates belonged to the same sequence type (ST-632). All subjects had prior international travel and antimicrobial exposure.
To evaluate the impact of changes to urine testing orderables in computerized physician order entry (CPOE) system on urine culturing practices.
Retrospective before-and-after study.
A 1,250-bed academic tertiary-care referral center.
Hospitalized adults who had ≥1 urine culture performed during their stay.
The intervention (implemented in April 2017) consisted of notifications to providers, changes to order sets, and inclusion of the new urine culture reflex tests in commonly used order sets. We compared the urine culture rates before the intervention (January 2015 to April 2016) and after the intervention (May 2016 to August 2017), adjusting for temporal trends.
During the study period, 18,954 inpatients (median age, 62 years; 68.8% white and 52.3% female) had 24,569 urine cultures ordered. Overall, 6,662 urine cultures (27%) were positive. The urine culturing rate decreased significantly in the postintervention period for any specimen type (38.1 per 1,000 patient days preintervention vs 20.9 per 1,000 patient days postintervention; P < .001), clean catch (30.0 vs 18.7; P < .001) and catheterized urine (7.8 vs 1.9; P < .001). Using an interrupted time series model, urine culture rates decreased for all specimen types (P < .05).
Our intervention of changes to order sets and inclusion of the new urine culture reflex tests resulted in a 45% reduction in the urine cultures ordered. CPOE system format plays a vital role in reducing the burden of unnecessary urine cultures and should be implemented in combination with other efforts.
Objectives: Prior research has identified numerous genetic (including sex), education, health, and lifestyle factors that predict cognitive decline. Traditional model selection approaches (e.g., backward or stepwise selection) attempt to find one model that best fits the observed data, risking interpretations that only the selected predictors are important. In reality, several predictor combinations may fit similarly well but result in different conclusions (e.g., about size and significance of parameter estimates). In this study, we describe an alternative method, Information-Theoretic (IT) model averaging, and apply it to characterize a set of complex interactions in a longitudinal study on cognitive decline. Methods: Here, we used longitudinal cognitive data from 1256 late–middle aged adults from the Wisconsin Registry for Alzheimer’s Prevention study to examine the effects of sex, apolipoprotein E (APOE) ɛ4 allele (non-modifiable factors), and literacy achievement (modifiable) on cognitive decline. For each outcome, we applied IT model averaging to a set of models with different combinations of interactions among sex, APOE, literacy, and age. Results: For a list-learning test, model-averaged results showed better performance for women versus men, with faster decline among men; increased literacy was associated with better performance, particularly among men. APOE had less of an association with cognitive performance in this age range (∼40–70 years). Conclusions: These results illustrate the utility of the IT approach and point to literacy as a potential modifier of cognitive decline. Whether the protective effect of literacy is due to educational attainment or intrinsic verbal intellectual ability is the topic of ongoing work. (JINS, 2019, 25, 119–133)
Objectives: A major challenge in cognitive aging is differentiating preclinical disease-related cognitive decline from changes associated with normal aging. Neuropsychological test authors typically publish single time-point norms, referred to here as unconditional reference values. However, detecting significant change requires longitudinal, or conditional reference values, created by modeling cognition as a function of prior performance. Our objectives were to create, depict, and examine preliminary validity of unconditional and conditional reference values for ages 40–75 years on neuropsychological tests. Method: We used quantile regression to create growth-curve–like models of performance on tests of memory and executive function using participants from the Wisconsin Registry for Alzheimer’s Prevention. Unconditional and conditional models accounted for age, sex, education, and verbal ability/literacy; conditional models also included past performance on and number of prior exposures to the test. Models were then used to estimate individuals’ unconditional and conditional percentile ranks for each test. We examined how low performance on each test (operationalized as <7th percentile) related to consensus-conference–determined cognitive statuses and subjective impairment. Results: Participants with low performance were more likely to receive an abnormal cognitive diagnosis at the current visit (but not later visits). Low performance was also linked to subjective and informant reports of worsening memory function. Conclusions: The percentile-based methods and single-test results described here show potential for detecting troublesome within-person cognitive change. Development of reference values for additional cognitive measures, investigation of alternative thresholds for abnormality (including multi-test criteria), and validation in samples with more clinical endpoints are needed. (JINS, 2019, 25, 1–14)
To determine the prevalence of Clostridium difficile colonization among patients who meet the 2017 IDSA/SHEA C. difficile infection (CDI) Clinical Guideline Update criteria for the preferred patient population for C. difficile testing.
Tertiary-care hospital in St. Louis, Missouri.
Patients whose diarrheal stool samples were submitted to the hospital’s clinical microbiology laboratory for C. difficile testing (toxin EIA) from August 2014 to September 2016.
Electronic and manual chart review were used to determine whether patients tested for C. difficile toxin had clinically significant diarrhea and/or any alternate cause for diarrhea. Toxigenic C. difficile culture was performed on all stool specimens from patients with clinically significant diarrhea and no known alternate cause for their diarrhea.
A total of 8,931 patients with stool specimens submitted were evaluated: 570 stool specimens were EIA positive (+) and 8,361 stool specimens were EIA negative (−). Among the EIA+stool specimens, 107 (19% of total) were deemed eligible for culture. Among the EIA− stool specimens, 515 (6%) were eligible for culture. One EIA+stool specimen (1%) was toxigenic culture negative. Among the EIA− stool specimens that underwent culture, toxigenic C. difficile was isolated from 63 (12%).
Most patients tested for C. difficile do not have clinically significant diarrhea and/or potential alternate causes for diarrhea. The prevalence of toxigenic C. difficile colonization among EIA− patients who met the IDSA/SHEA CDI guideline criteria for preferred patient population for C. difficile testing was 12%.
OBJECTIVES/SPECIFIC AIMS: Clostridium difficile is the most common cause of infectious antibiotic associated diarrhea. It is often refractory to antimicrobial therapy and fecal microbiota transplantation (FMT) is emerging as a therapeutic option. The objective is to characterize the direct effects of FMT on the gut microbiota. METHODS/STUDY POPULATION: Fecal specimens were obtained from a cohort of 29 subjects with recurrent C. difficile infection who received FMTs from 1 of 4 healthy donors as part of a phase 2 trial (Rebiotix). Fecal specimens were collected from the subject before FMT and up to 6 months post FMT. 16S rRNA sequencing and whole-genome shotgun sequencing were used to assess microbial community composition as compared by weighted Unifrac. RESULTS/ANTICIPATED RESULTS: Before treatment, the microbial community of subjects with C. difficile infection was highly distinct from the composition of the healthy donors in terms of metabolic profile. Quantification of phylogenetic community distance from donor by weighted Unifrac distance showed a significant decrease within the 1st week (Wilcoxon rank sum, p<0.01). This metric was predictive of both treatment failures and antibiotic resistance gene count (LR=22.45, p<0.0001). DISCUSSION/SIGNIFICANCE OF IMPACT: We conclude that distance from donor is a useful metric to quantify FMT success and that FMTs are a promising treatment for otherwise untreatable carriage of antibiotic resistance genes and organisms.
To evaluate healthcare worker (HCW) risk of self-contamination when donning and doffing personal protective equipment (PPE) using fluorescence and MS2 bacteriophage.
Prospective pilot study.
A total of 36 HCWs were included in this study: 18 donned/doffed contact precaution (CP) PPE and 18 donned/doffed Ebola virus disease (EVD) PPE.
HCWs donned PPE according to standard protocols. Fluorescent liquid and MS2 bacteriophage were applied to HCWs. HCWs then doffed their PPE. After doffing, HCWs were scanned for fluorescence and swabbed for MS2. MS2 detection was performed using reverse transcriptase PCR. The donning and doffing processes were videotaped, and protocol deviations were recorded.
Overall, 27% of EVD PPE HCWs and 50% of CP PPE HCWs made ≥1 protocol deviation while donning, and 100% of EVD PPE HCWs and 67% of CP PPE HCWs made ≥1 protocol deviation while doffing (P=.02). The median number of doffing protocol deviations among EVD PPE HCWs was 4, versus 1 among CP PPE HCWs. Also, 15 EVD PPE protocol deviations were committed by doffing assistants and/or trained observers. Fluorescence was detected on 8 EVD PPE HCWs (44%) and 5 CP PPE HCWs (28%), most commonly on hands. MS2 was recovered from 2 EVD PPE HCWs (11%) and 3 CP PPE HCWs (17%).
Protocol deviations were common during both EVD and CP PPE doffing, and some deviations during EVD PPE doffing were committed by the HCW doffing assistant and/or the trained observer. Self-contamination was common. PPE donning/doffing are complex and deserve additional study.
Introduction/Innovation Concept: Free Open Access Medical education (FOAM) is a rapidly emerging medium for the dissemination of medical knowledge, especially in Emergency Medicine. However, the most contributors to FOAM are EM attendings who write on established platforms which they also maintain. EM learners have difficulty breaking into this quickly evolving field. In an effort to encourage FOAM involvement of trainees early in their careers, CanadiEM recruited 10 junior residents and medical students with the purpose of developing the skills necessary to contribute to FOAM. These Junior Editors actively participate in the blog workflow, developing writing, editorial, and management skills necessary to operate a high-traffic EM website. Methods: Potential candidates were recruited by placing an advertisement and application on the CanadiEM website. 10 medical students or junior residents were invited to online group video interviews and were all accepted as Junior Editors (JE). Senior CanadiEM staff held online training sessions for all new JEs on how to use Wordpress to create, edit and publish posts, as well as basics in Search Engine Optimization. The junior editors collaboratively developed an instructional document containing the information they learned during these sessions. JEs then volunteered for editorial jobs via an online messaging system (Slack) as they became available. After uploading the draft of each post, the final products are reviewed by senior Editor and feedback was given to each JE. Curriculum, Tool, or Material: All JEs have learned to use the Wordpress blogging platform to create, edit, and upload posts; optimize blog posts for search engines. Following their own interests, some JEs have also learned to edit podcasts, promote the blog on social media resources (Twitter and Facebook), create infographics, and copy-edit blog posts. Conclusion: After 8 months, the JE program has yielded 6 very active editors who maintain a strong blog workflow, have well-developed social media skills, and are actively involved in developing their own content for future posts. The JE program is a strong pathway to introduce medical trainees to both the technical and creative aspects of FOAM and serves as a novel approach to transition students from passive utilization of online content to active contributors.
The aetiology and outcomes for patients with acquired subglottic stenosis are highly variable. This study aimed to identify risk factors for subglottic stenosis and patient characteristics that predict long-term clinical outcomes.
A retrospective review was performed on 63 patients with subglottic stenosis and 63 age-matched controls. Patient demographics and clinical characteristics were compared. Subglottic stenosis patients were further grouped according to tracheostomy status (i.e. tracheostomy never required, tracheostomy initially required but patient eventually decannulated, and tracheostomy-dependent). Patient factors from these three groups were then compared to evaluate risk factors for long-term tracheostomy dependence.
Compared to controls, patients with subglottic stenosis had a significantly higher body mass index (30.8 vs 26.0 kg/m2; p < 0.001) and were more likely to have diabetes (23.8 per cent vs 7.94 per cent; p = 0.01). Comparing tracheostomy outcomes within the subglottic stenosis group, body mass index trended towards significance (p = 0.08). Age, gender, socio-economic status, subglottic stenosis aetiology and other co-morbidities did not correlate with outcome.
Obesity and diabetes are significant risk factors for acquiring subglottic stenosis. Further investigations are required to determine if obesity is also a predictor for failed tracheostomy decannulation in subglottic stenosis.
Objectives: Intraindividual cognitive variability (IICV) has been shown to differentiate between groups with normal cognition, mild cognitive impairment (MCI), and dementia. This study examined whether baseline IICV predicted subsequent mild to moderate cognitive impairment in a cognitively normal baseline sample. Methods: Participants with 4 waves of cognitive assessment were drawn from the Wisconsin Registry for Alzheimer’s Prevention (WRAP; n=684; 53.6(6.6) baseline age; 9.1(1.0) years follow-up; 70% female; 74.6% parental history of Alzheimer’s disease). The primary outcome was Wave 4 cognitive status (“cognitively normal” vs. “impaired”) determined by consensus conference; “impaired” included early MCI (n=109), clinical MCI (n=11), or dementia (n=1). Primary predictors included two IICV variables, each based on the standard deviation of a set of scores: “6 Factor IICV” and “4 Test IICV”. Each IICV variable was tested in a series of logistic regression models to determine whether IICV predicted cognitive status. In exploratory analyses, distribution-based cutoffs incorporating memory, executive function, and IICV patterns were used to create and test an MCI risk variable. Results: Results were similar for the IICV variables: higher IICV was associated with greater risk of subsequent impairment after covariate adjustment. After adjusting for memory and executive functioning scores contributing to IICV, IICV was not significant. The MCI risk variable also predicted risk of impairment. Conclusions: While IICV in middle-age predicts subsequent impairment, it is a weaker risk indicator than the memory and executive function scores contributing to its calculation. Exploratory analyses suggest potential to incorporate IICV patterns into risk assessment in clinical settings. (JINS, 2016, 22, 1016–1025)
Globus pharyngeus has been linked to salivary hypofunction. We hypothesise that a considerable portion of the globus experienced by patients is due to a drying effect secondary to anticholinergic medication use; this study aimed to determine their association.
A cross-sectional study was conducted of 270 patients who presented to a laryngology practice over 6 months. Participants rated globus sensation on a 5-point severity scale, with those scoring 0 considered as controls (non-globus). Participants were excluded if they had a likely cause of globus. Scores were compared with participants’ medication lists, co-morbidities, age and gender, and evaluated using multivariate analysis, with significance set at p < 0.05.
Any participant taking at least 2 anticholinergic medications had a 3.52 increased odds (p = 0.02) of experiencing globus. A previous diagnosis of gastroesophageal reflux disease was also significantly associated with globus (p = 0.004), with an odds ratio of 3.75.
A substantial portion of idiopathic globus may be due to anticholinergic use or reflux. The findings implicate medication use as a risk factor for globus. An awareness of these associations is invaluable for identifying cause and treating globus.
To determine whether Clostridium difficile is present in the food of hospitalized patients and to estimate the risk of subsequent colonization associated with C. difficile in food.
This was a prospective cohort study of inpatients at a university-affiliated tertiary care center, May 9, 2011–July 12, 2012. Enrolled patients submitted a portion of food from each meal. Patient stool specimens and/or rectal swabs were collected at enrollment, every 3 days thereafter, and at discharge, and were cultured for C. difficile. Clinical data were reviewed for evidence of infection due to C. difficile. A stochastic, discrete event model was developed to predict exposure to C. difficile from food, and the estimated number of new colonization events from food exposures per 1,000 admissions was determined.
A total of 149 patients were enrolled and 910 food specimens were obtained. Two food specimens from 2 patients were positive for C. difficile (0.2% of food samples; 1.3% of patients). Neither of the 2 patients was colonized at baseline with C. difficile. Discharge colonization status was available for 1 of the 2 patients and was negative. Neither was diagnosed with C. difficile infection while hospitalized or during the year before or after study enrollment. Stochastic modeling indicated contaminated hospital food would be responsible for less than 1 newly colonized patient per 1,000 hospital admissions.
The recovery of C. difficile from the food of hospitalized patients was rare. Modeling suggests hospital food is unlikely to be a source of C. difficile acquisition.
We aimed to determine the frequency of qacA/B chlorhexidine tolerance genes and high-level mupirocin resistance among MRSA isolates before and after the introduction of a chlorhexidine (CHG) daily bathing intervention in a surgical intensive care unit (SICU).
Retrospective cohort study (2005–2012)
A large tertiary-care center
Patients admitted to SICU who had MRSA surveillance cultures of the anterior nares
A random sample of banked MRSA anterior nares isolates recovered during (2005) and after (2006–2012) implementation of a daily CHG bathing protocol was examined for qacA/B genes and high-level mupirocin resistance. Staphylococcal cassette chromosome mec (SCCmec) typing was also performed.
Of the 504 randomly selected isolates (63 per year), 36 (7.1%) were qacA/B positive (+) and 35 (6.9%) were mupirocin resistant. Of these, 184 (36.5%) isolates were SCCmec type IV. There was a significant trend for increasing qacA/B (P=.02; highest prevalence, 16.9% in 2009 and 2010) and SCCmec type IV (P<.001; highest prevalence, 52.4% in 2012) during the study period. qacA/B(+) MRSA isolates were more likely to be mupirocin resistant (9 of 36 [25%] qacA/B(+) vs 26 of 468 [5.6%] qacA/B(−); P=.003).
A long-term, daily CHG bathing protocol was associated with a change in the frequency of qacA/B genes in MRSA isolates recovered from the anterior nares over an 8-year period. This change in the frequency of qacA/B genes is most likely due to patients in those years being exposed in prior admissions. Future studies need to further evaluate the implications of universal CHG daily bathing on MRSA qacA/B genes among hospitalized patients.
This was a randomized controlled pilot study of Lactobacillus rhamnosus GG versus standard of care to prevent gastrointestinal multidrug-resistant organism colonization in intensive care unit patients. Among 70 subjects, there were no significant differences in acquisition or loss of any multidrug-resistant organisms (P>.05) and no probiotic-associated adverse events.
Infect. Control Hosp. Epidemiol. 2015;36(12):1451–1454