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The purpose of this study was to describe the recent trends of invasive and noninvasive β-hemolytic Streptococcus cultures in the Veterans’ Affairs (VA) cohort from 2009 to 2018.
Retrospective cohort study from January 1, 2009, to January 1, 2019.
Veterans’ Affairs medical centers.
Patients or participants:
All patients aged 18 years and older with cultures positive for β-hemolytic Streptococcus at a VA facility were included in the study.
Data were retrieved from the VA Corporate Data Warehouse using structure query language through the SQL Server Management Studio software.
Between 2009 and 2018, there were 40,625 patients with cultures with β-hemolytic Streptococcus. The median age was 64 years (interquartile range [IQR], 55–71) and the median Charlson comorbidity index was 4 (IQR, 2–7). Distributions for each type of β-hemolytic Streptococcus based on site of culture are provided. The 30-day all-cause mortality rate from all invasive β-hemolytic Streptococcus cases was 2.3%, and the 90-day all-cause mortality rate was 4.4%. The 30- and 90-day all-cause mortality rates for Streptococcus cases were higher for group A (3.9% and 6.1% respectively) and for groups C and G combined (3.2% and 6.1%, respectively) than for group B (2.0% and 4.0%, respectively).
Trends of cultures for invasive and noninvasive β-hemolytic Streptococcus suggest an association with disease and mortality. The burden associated with β-hemolytic Streptococcus infections should not be underestimated.
Clostridium difficile infection (CDI) is a reportable hospital metric associated with significant healthcare expenditures. The epidemiology of CDI is pivotal to the implementation of preventative measures.
To portray temporal CDI trends in Veterans Health Administration (VA) hospitals.
A retrospective analysis of veterans who had stool testing for C. difficile.
VA acute-care hospitals within the continental United States.
Data were mined from the VA’s Corporate Data Warehouse. CDI is reported per 10,000 patient days.
From 2006 to 2016, 472,346 patients had C. difficile testing. Overall, decreases in incidence of total CDI (16.81 to 13.66) and hospital-onset healthcare facility-associated (HO-HCFA) CDI (10.87 to 6.41) were observed. Temporal increases in the incidence of total and HO-HCFA CDI were associated with the increased use of molecular testing (P < .0001). Decreased use of fluoroquinolones (P < .0001), clindamycin (P = .0006), and third-generation cephalosporins (P = .0002) correlated with decreased rates of CDI, but VA mandatory reporting did not influence CDI rates (P = .24). The overall crude 30-day mortality of patients with CDI decreased from 2.17 deaths per 10,000 patient days in 2006 to 1.41 in 2016. The frequency of International Classification of Disease, Ninth/Tenth Revision (ICD-9/10) discharge diagnosis for CDI was 73.3%.
Molecular testing was associated with increased incidence of CDI. Controlling CDI is likely multifactorial. Although the VA initiative to report cases of hospital-acquired CDI was not significant in our model, the advent of stewardship programs throughout the VA and reductions in the use of third-generation cephalosporins, fluoroquinolones, and clindamycin were significantly associated with reduced rates of CDI.
To describe an outbreak of severe Group A Streptococcus (GAS) infections that appeared to be associated with use of a biologic dermal substitute on foot wounds
Retrospective cohort study of cases and similar uninfected patients
Patients attending the podiatry clinic at a Veterans Affairs Medical Center between July 2011 and November 2011
Microbiology laboratory data were reviewed for the calendar year, a case definition was established and use of the biologic dermal substitute was discontinued. Staff were cultured to identify potentially colonized employees. A case–cohort study was designed to investigate risk factors for disease. Emm typing and pulsed field gel electrophoresis (PFGE) were performed to identify strain similarity.
In 10 months, 14 cases were identified, and 4 of these patients died. All strains were emm type 28 and were identical according to PFGE. Discontinuation of biologic dermal substitute use halted the outbreak. A prior stroke was more common in the case cohort vs uninfected patient cohorts. The number of patients attending the clinic on 13 probable transmission days was significantly higher than on nontransmission days. We identified 2 patients who were present in the clinic on all but 1 probable transmission day. Surveillance cultures of podiatry clinic staff and cultures of the same lot of retained graft material were negative.
A carrier was not identified, and we believe the outbreak was associated with inter-patient transmission likely due to lapses in infection control techniques. No additional cases have been identified in >3 years following the resumption of dermal substitute use in May 2012.
Infect. Control Hosp. Epidemiol. 2016;37(3):306–312
To determine whether reuse of insulin pens among multiple patients resulted in transmission of bloodborne pathogens (BBP).
Retrospective cohort study.
Two Veterans Affairs medical centers.
Veterans who received insulin via insulin pens from 2010 to 2013.
Patients were identified through electronic health records, notified of possible exposure, and serotested for human immunodeficiency virus, hepatitis C virus (HCV), and hepatitis B virus. Newly discovered case patients were assessed in relation to potential proximate patients to determine viral strain relatedness by HCV envelope (env) gene sequencing.
Of 1,791 hospitalized veterans who received insulin via insulin pen, 1,155 were tested for at least 1 viral infection after exposure. Of these, 67 patients were newly diagnosed with 1 or more viral BBPs. For human immunodeficiency virus and hepatitis B virus no additional strain testing of case or proximate patients was possible; 8 HCV cases and 45 proximates (40 unique patients; 5 patients were positive for 2 genotypes) were identified as needing strain testing. Only 3 cases and their 19 proximates had samples available for further testing. None of the 26 remaining proximate patients had blood available for further testing. Median genetic distance between the HCV env sequences of those available for additional testing ranged from 14% to 24%, indicating nonrelatedness.
Our investigation revealed that exposure to insulin pen reuse did not result in HCV transmission among patients who had viral genetic analysis performed. Analysis for any additional potential transmission of blood-borne pathogens was limited by the available samples.
Infect Control Hosp Epidemiol 2015;36(10):1121–1129