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Clinician education and prospective audit and feedback interventions, deployed separately and concurrently, did not reduce antimicrobial use errors or rates compared to a control group of general medicine inpatients at our public hospital. Additional research is needed to define the optimal scope and intensity of hospital antimicrobial stewardship interventions.
To identify modifiable risk factors for acquisition of Klebsiella pneumoniae carbapenemase-producing Enterobacteriaceae (KPC) colonization among long-term acute-care hospital (LTACH) patients.
Multicenter, matched case-control study.
Four LTACHs in Chicago, Illinois.
Each case patient included in this study had a KPC-negative rectal surveillance culture on admission followed by a KPC-positive surveillance culture later in the hospital stay. Each matched control patient had a KPC-negative rectal surveillance culture on admission and no KPC isolated during the hospital stay.
From June 2012 to June 2013, 2,575 patients were admitted to 4 LTACHs; 217 of 2,144 KPC-negative patients (10.1%) acquired KPC. In total, 100 of these patients were selected at random and matched to 100 controls by LTACH facility, admission date, and censored length of stay. Acquisitions occurred a median of 16.5 days after admission. On multivariate analysis, we found that exposure to higher colonization pressure (OR, 1.02; 95% CI, 1.01–1.04; P=.002), exposure to a carbapenem (OR, 2.25; 95% CI, 1.06–4.77; P=.04), and higher Charlson comorbidity index (OR, 1.14; 95% CI, 1.01–1.29; P=.04) were independent risk factors for KPC acquisition; the odds of KPC acquisition increased by 2% for each 1% increase in colonization pressure.
Higher colonization pressure, exposure to carbapenems, and a higher Charlson comorbidity index independently increased the odds of KPC acquisition among LTACH patients. Reducing colonization pressure (through separation of KPC-positive patients from KPC-negative patients using strict cohorts or private rooms) and reducing carbapenem exposure may prevent KPC cross transmission in this high-risk patient population.
Prevalence of blaKPC-encoding Enterobacteriaceae (KPC) in Chicago long-term acute care hospitals (LTACHs) rose rapidly after the first recognition in 2007. We studied the epidemiology and transmission capacity of KPC in LTACHs and the effect of patient cohorting.
Data were available from 4 Chicago LTACHs from June 2012 to June 2013 during a period of bundled interventions. These consisted of screening for KPC rectal carriage, daily chlorhexidine bathing, medical staff education, and 3 cohort strategies: a pure cohort (all KPC-positive patients on 1 floor), single rooms for KPC-positive patients, and a mixed cohort (all KPC-positive patients on 1 floor, supplemented with KPC-negative patients). A data-augmented Markov chain Monte Carlo (MCMC) method was used to model the transmission process.
Average prevalence of KPC colonization was 29.3%. On admission, 18% of patients were colonized; the sensitivity of the screening process was 81%. The per admission reproduction number was 0.40. The number of acquisitions per 1,000 patient days was lowest in LTACHs with a pure cohort ward or single rooms for colonized patients compared with mixed-cohort wards, but 95% credible intervals overlapped.
Prevalence of KPC in LTACHs is high, primarily due to high admission prevalence and the resultant impact of high colonization pressure on cross transmission. In this setting, with an intervention in place, patient-to-patient transmission is insufficient to maintain endemicity. Inclusion of a pure cohort or single rooms for KPC-positive patients in an intervention bundle seemed to limit transmission compared to use of a mixed cohort.
Infect Control Hosp Epidemiol 2015;36(10):1148–1154
We evaluated the effectiveness of daily chlorhexidine gluconate (CHG) bathing in decreasing skin carriage of Klebsiella pneumoniae carbapenemase–producing Enterobacteriaceae (KPC) among long-term acute care hospital patients. CHG bathing reduced KPC skin colonization, particularly when CHG skin concentrations greater than or equal to 128 μg/mL were achieved.
To identify differences in organizational culture and better understand motivators to implementation of abundle intervention to control Klebsiella pneumoniae carbapenemase–producing Enterobacteriaceae (KPC).
Four long-term acute care hospitals (LTACHs) in Chicago.
LTACH staff across 3 strata of employees (administration, midlevel management, and frontline clinical workers).
Qualitative interviews or focus groups and completion of a quantitative questionnaire.
Eighty employees (frontline, 72.5%; midlevel, 17.5%; administration, 10%) completed surveys and participated in qualitative discussions in August 2012. Although 82.3% of respondents felt that quality improvement was a priority at their LTACH, there were statistically significant differences in organizational culture between staff strata, with administrative-level having higher organizational culture scores (ie, more favorable responses) than midlevel or frontline staff. When asked to rank the success of the KPC control program, mean response was 8.0 (95% confidence interval, 7.6–8.5), indicating a high level of agreement with the perception that the program was a success. Patient safety and personal safety were reported most often as personal motivators for intervention adherence. The most convergent theme related to prevention across groups was that proper hand hygiene is vital to prevention of KPC transmission.
Despite differences in organizational culture across 3 strata of LTACH employees, the high degree of convergence in motivation, understanding, and beliefs related to implementation of a KPC control bundle suggests that all levels of staff may be able to align perspectives when faced with a key infection control problem and quality improvement initiative.
To develop prediction algorithms for the presence of a central vascular catheter in hospitalized patients with use of data present in an electronic health record. Such algorithms could be used for measurement of device utilization rates and for clinical decision support rules.
John H. Stroger, Jr, Hospital of Cook County, a 464-bed public hospital in Chicago, Illinois.
Patients admitted to the medical intensive care unit from May 31, 2005 through June 26, 2006 (derivation data set, May 31, 2005-September 28, 2005; validation data set, September 29, 2005-June 28, 2006).
Covariates were collected from the electronic medical record for each patient; the outcome variable was presence of a central vascular device. Multivariate models were developed using the derivation set and the generalized estimating equation. Three models, each with increasing database requirements, were validated using the validation set. Device utilization ratios and performance characteristics were calculated.
Although Charlson score and duration of intensive care unit stay were significant predictors in all models, factors that indicated use or presence of a central line were also important. Device utilization rates derived from the algorithmic models were as accurate as those obtained using manual sampling.
Automated calculation of central vascular catheter use is both feasible and accurate, providing estimates statistically similar to those obtained using manual surveillance. Prediction modeling of central vascular catheter use may enable automated surveillance of bloodstream infections and enhance important prevention interventions, such as timely removal of unnecessary central lines.
To describe and measure reliability of a computer-assisted method of case vignette assembly and expert review to assess the appropriateness of antimicrobial therapy for hospitalized adults.
Feasibility and reliability analysis of computer-assisted tool used to compare the effects of antimicrobial stewardship interventions.
Public teaching hospital.
Randomly selected adult antimicrobial recipients admitted to inpatient medicine services.
Clinical data abstracted from 504 paper medical records were merged with computerized laboratory and pharmacy data to assemble case vignettes that underwent expert review for appropriateness. We performed 3 validations, as follows: data for 35 vignettes abstracted independently by 2 research assistants were assessed for interrater agreement, expert review of 24 vignettes was compared with review of the corresponding paper medical records, and interrater reliability of antimicrobial appropriateness assessments by 2 experts was determined for 70 case vignettes.
Vignette assembly and expert review each required 10–12 minutes per case. Potentially important discrepancies occurred in 0%–32% of clinical findings abstracted independently by 2 research assistants. Expert review of 24 vignettes and the corresponding full paper medical records yielded fair agreement (kappa, 0.30). The 2 experts identified inappropriate initial antimicrobial therapy in 67% and 61% of case vignettes reviewed independently; interrater agreement was improved after sequential case discussion and stringent application of appropriateness criteria (kappa, 0.72).
Our case vignette assembly and expert review method is efficient, but improvements in both technical and human performance are needed to be able to yield valid estimates of the prevalence of inappropriate antimicrobial use. Assessments of antimicrobial appropriateness require validation.
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