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Background: Carbapenemase genes in carbapenem-resistant Enterobacterales (CP-CRE) may be transmitted between patients and bacteria. Reported rates of carbapenemase genes vary widely, and it is unclear whether having a carbapenemase gene portends worse outcomes given that all patients with CRE infections have limited treatment options. Methods: Using active population- and laboratory-based active surveillance data collected by the US CDC-funded Georgia Emerging Infections Program from 2011 to 2020, we assessed the frequency of carbapenemase genes in a convenience sample of CRE isolates using whole-genome sequencing (WGS), and we investigated risk factors for carbapenemase positivity. Only the first isolate per patient in a 30-day period was included. We compared characteristics of patients with CP-CRE and non–CP-CRE. Using multivariable log binomial regression, we assessed the association of carbapenemase gene positivity and 90-day mortality. Results: Of 284 CRE isolates, 171 isolates (60.2%) possessed a carbapenemase gene (Table 1), and KPC-3 was the most common carbapenemase gene (80.7%), with only 7 isolates possessing NDM (Table 2). No isolates possessed >1 carbapenemase gene, and most isolates were from urine (82.4%) (Table 1). Carbapenemase gene positivity was associated with lower age, male sex, black race, infection with Klebsiella pneumoniae, polymicrobial infection, having an indwelling medical device, receiving chronic dialysis, and prior stay in a long-term acute-care hospital, long-term care facility, and/or prior hospitalization in the last year. The 90-day mortality rates were similar in patients with non–CP-CRE and CP-CRE: 24.8% versus 25.7% (P = .86). In multivariable analysis, carbapenemase gene presence was not associated with 90-day mortality (adjusted risk ratio, 0.82; 95% CI, 0.50–1.35) when adjusting for CCI, infection with Klebsiella pneumoniae, and chronic dialysis use. Conclusions: The frequency of CP-CRE among CRE was high in this study, but unlike prior studies, the 90-day mortality rates wer similar in patients with CP-CRE compared to non–CP-CRE. Our results provide novel associations (eg, lower age, male sex, infection with Klebsiella pneumoniae, and indwelling medical devices) that infection preventionists could use to target high-risk patients for screening or isolation prior to CP-CRE detection.
Hospitals caring for patients with high-consequence pathogens may need to safely manage large volumes of category A waste. Using biological indicators to assess for successful sterilization, autoclave cycle parameters that would inactivate 4 categories of waste were identified and validated utilizing a STERIS Amsco 630LS Steam Sterilizer.
To determine the impact of an inpatient stewardship intervention targeting fluoroquinolone use on inpatient and postdischarge Clostridioides difficile infection (CDI).
We used an interrupted time series study design to evaluate the rate of hospital-onset CDI (HO-CDI), postdischarge CDI (PD-CDI) within 12 weeks, and inpatient fluoroquinolone use from 2 years prior to 1 year after a stewardship intervention.
An academic healthcare system with 4 hospitals.
All inpatients hospitalized between January 2017 and September 2020, excluding those discharged from locations caring for oncology, bone marrow transplant, or solid-organ transplant patients.
Introduction of electronic order sets designed to reduce inpatient fluoroquinolone prescribing.
Among 163,117 admissions, there were 683 cases of HO-CDI and 1,104 cases of PD-CDI. In the context of a 2% month-to-month decline starting in the preintervention period (P < .01), we observed a reduction in fluoroquinolone days of therapy per 1,000 patient days of 21% after the intervention (level change, P < .05). HO-CDI rates were stable throughout the study period. In contrast, we also detected a change in the trend of PD-CDI rates from a stable monthly rate in the preintervention period to a monthly decrease of 2.5% in the postintervention period (P < .01).
Our systemwide intervention reduced inpatient fluoroquinolone use immediately, but not HO-CDI. However, a downward trend in PD-CDI occurred. Relying on outcome measures limited to the inpatient setting may not reflect the full impact of inpatient stewardship efforts.
To evaluate whether a series of quality improvement interventions to promote safe perioperative use of cephalosporins in penicillin-allergic patients improved use of first-line antibiotics and decreased costs.
Before-and-after trial following several educational interventions.
Academic medical center.
This study included patients undergoing a surgical procedure involving receipt of a perioperative antibiotic other than a penicillin or carbapenem between January 1, 2017, and August 31, 2019. Patients with and without a penicillin allergy label in their electronic medical record were compared with respect to the percentage who received a cephalosporin and average antibiotic cost per patient.
A multidisciplinary team from infectious diseases, allergy, anesthesiology, surgery, and pharmacy surveyed anesthesiology providers about their use of perioperative cephalosporins in penicillin-allergic patients. Using findings from that survey, the team designed a decision-support algorithm for safe utilization and provided 2 educational forums to introduce this algorithm, emphasizing the safety of cefazolin or cefuroxime in penicillin-allergic patients without history of a severe delayed hypersensitivity reaction.
The percentage of penicillin-allergic patients receiving a perioperative cephalosporin improved from ∼34% to >80% following algorithm implementation and the associated educational interventions. This increase in cephalosporin use was associated with a ∼50% reduction in antibiotic cost per penicillin-allergic patient. No significant adverse reactions were reported.
An educational antibiotic stewardship intervention produced a significant change in clinician behavior. A simple intervention can have a significant impact, although further study is needed regarding whether this response is sustained and whether an educational intervention is similarly effective in other healthcare systems.
Background: Effective inpatient stewardship initiatives can improve antibiotic prescribing, but impact on outcomes like Clostridioides difficile infections (CDIs) is less apparent. However, the effect of inpatient stewardship efforts may extend to the postdischarge setting. We evaluated whether an intervention targeting inpatient fluoroquinolone (FQ) use in a large healthcare system reduced incidence of postdischarge CDI. Methods: In August 2019, 4 acute-care hospitals in a large healthcare system replaced standalone FQ orders with order sets containing decision support. Order sets redirected prescribers to syndrome order sets that prioritize alternative antibiotics. Monthly patient days (PDs) and antibiotic days of therapy (DOT) administered for FQs and NHSN-defined broad-spectrum hospital-onset (BS-HO) antibiotics were calculated using patient encounter data for the 23 months before and 13 months after the intervention (COVID-19 admissions in the previous 7 months). We evaluated hospital-onset CDI (HO-CDI) per 1,000 PD (defined as any positive test after hospital day 3) and 12-week postdischarge (PDC- CDI) per 100 discharges (any positive test within healthcare system <12 weeks after discharge). Interrupted time-series analysis using generalized estimating equation models with negative binomial link function was conducted; a sensitivity analysis with Medicare case-mix index (CMI) adjustment was also performed to control for differences after start of the COVID-19 pandemic. Results: Among 163,117 admissions, there were 683 HO-CDIs and 1,009 PDC-CDIs. Overall, FQ DOT per 1,000 PD decreased by 21% immediately after the intervention (level change; P < .05) and decreased at a consistent rate throughout the entire study period (−2% per month; P < .01) (Fig. 1). There was a nonsignificant 5% increase in BS-HO antibiotic use immediately after intervention and a continued increase in use after the intervention (0.3% per month; P = .37). HO-CDI rates were stable throughout the study period, with a nonsignificant level change decrease of 10% after the intervention. In contrast, there was a reversal in the trend in PDC-CDI rates from a 0.4% per month increase in the preintervention period to a 3% per month decrease in the postintervention period (P < .01). Sensitivity analysis with adjustment for facility-specific CMI produced similar results but with wider confidence intervals, as did an analysis with a distinct COVID-19 time point. Conclusion: Our systemwide intervention using order sets with decision support reduced inpatient FQ use by 21%. The intervention did not significantly reduce HO-CDI but significantly decreased the incidence of CDI within 12 weeks after discharge. Relying on outcome measures limited to inpatient setting may not reflect the full impact of inpatient stewardship efforts and incorporating postdischarge outcomes, such as CDI, should increasingly be considered.
To describe the epidemiology of carbapenem-resistant Enterobacterales (CRE) bacteriuria and to determine whether urinary catheters increase the risk of subsequent CRE bacteremia.
Using active population- and laboratory-based surveillance we described a cohort of patients with incident CRE bacteriuria and identified risk factors for developing CRE bacteremia within 1 year.
The study was conducted among the 8 counties of Georgia Health District 3 (HD3) in Atlanta, Georgia.
Residents of HD3 with CRE first identified in urine between 2012 and 2017.
We identified 464 patients with CRE bacteriuria (mean yearly incidence, 1.96 cases per 100,000 population). Of 425 with chart review, most had a urinary catheter (56%), and many resided in long-term care facilities (48%), had a Charlson comorbidity index >3 (38%) or a decubitus ulcer (37%). 21 patients (5%) developed CRE bacteremia with the same organism within 1 year. Risk factors for subsequent bacteremia included presence of a urinary catheter (odds ratio [OR], 8.0; 95% confidence interval [CI], 1.8–34.9), central venous catheter (OR, 4.3; 95% CI, 1.7–10.6) or another indwelling device (OR, 4.3; 95% CI, 1.6–11.4), urine culture obtained as an inpatient (OR, 5.7; 95% CI, 1.3–25.9), and being in the ICU in the week prior to urine culture (OR, 2.9; 95% CI, 1.1–7.8). In a multivariable analysis, urinary catheter increased the risk of CRE bacteremia (OR, 5.3; 95% CI, 1.2–23.6).
In patients with CRE bacteriuria, urinary catheters increase the risk of CRE bacteremia. Future interventions should aim to reduce inappropriate insertion and early removal of urinary catheters.
Background: Hospitalists play a critical role in antimicrobial stewardship as the primary antibiotic prescriber for many inpatients. We sought to describe antibiotic prescribing variation among hospitalists within a healthcare system. Methods: We created a novel metric of hospitalist-specific antibiotic prescribing by linking hospitalist billing data to hospital medication administration records in 4 hospitals (two 500-bed academic (AMC1 and AMC2), one 400-bed community (CH1), and one 100-bed community (CH2)) from January 2016 to December 2018. We attributed dates that a hospitalist electronically billed for a given patient as billed patient days (bPD) and mapped an antibiotic day of therapy (DOT) to a bPD. Each DOT was classified according to National Healthcare Safety Network antibiotic categories: broad-spectrum hospital-onset (BS-HO), broad-spectrum community-onset (BS-CO), anti-MRSA, and highest risk for Clostridioides difficile infection (CDI). DOT and bPD were pooled to calculate hospitalist-specific DOT per 1,000 bPD. Best subsets regression was performed to assess model fit and generate hospital and antibiotic category-specific models adjusting for patient-level factors (eg, age ≥65, ICD-10 codes for comorbidities and infections). The models were used to calculate predicted hospitalist-specific DOT and observed-to-expected ratios (O:E) for each antibiotic category. Kruskal-Wallis tests and pairwise Wilcoxon rank-sum tests were used to determine significant differences between median DOT per 1,000 bPD and O:E between hospitals for each antibiotic category. Results: During the study period, 116 hospitalists across 4 hospitals contributed a total of 437,303 bPD. Median DOT per 1,000 bPD varied between hospitals (BS-HO range, 46.7–84.2; BS-CO range, 63.3–100; anti-MRSA range, 48.4–65.4; CDI range, 82.0–129.4). CH2 had a significantly higher median DOT per 1,000 bPD compared to the academic hospitals (all antibiotic categories P < .001) and CH1 (BS-HO, P = .01; anti-MRSA, P = .02) (Fig. 1A). The 4 antibiotic groups at 4 hospitals resulted in 16 models, with good model fit for CH2 (R2 > 0.55 for all models), modest model fit for AMC2 (R2 = 0.46–0.55), fair model fit for CH1 (R2 = 0.19–0.35), and poor model fit for AMC1 (R2 < 0.12 for all models). Variation in hospitalist-specific O:E was moderate (IQR, 0.9–1.1). AMC1 showed greater variation than other hospitals, but we detected no significant differences in median O:E between hospitals (all antibiotic categories P > .10) (Fig. 1B). Conclusions: Adjusting for patient-level factors significantly reduced much of the variation in hospitalist-specific DOT per 1,000 bPD in some but not all hospitals, suggesting that unmeasured factors may drive antibiotic prescribing. This metric may represent a target for stewardship intervention, such as hospitalist-specific feedback of antibiotic prescribing practices.
Disclosures: Scott Fridkin, consulting fee - vaccine industry (various) (spouse)
Background: There is great enthusiasm for the potential of decision support tools embedded in the electronic medical record to improve antimicrobial use in hospitals. Yet they are often limited in their ability to change prescriber behavior. Analyzing these tools using an interactive sociotechnical approach (ISTA) can identify barriers and facilitators to the implementation of electronic decision support (EDS) in antimicrobial stewardship. Objective: To examine prescriber and antimicrobial steward perceptions of EDS using an ISTA approach in the preimplementation phase of an antimicrobial stewardship intervention. Methods: We conducted semistructured interviews with prescribers and stewards from 4 hospitals in 2 health systems in the context of a multicomponent intervention to improve the use of fluoroquinolones and extended-spectrum cephalosporins. Sites planned to implement various EDS elements including order sets, antimicrobial time outs, and audit with feedback stewardship notes in the medical record. Interviews elicited respondent perceptions about the planned intervention. Two analysts systematically coded transcripts using an ISTA framework in NVivo12 software. Results: Interviews with 64 respondents were conducted: 38 physicians, 7 nurses, 6 advanced practice providers, and 13 pharmacists. We identified 4 key sociotechnical interaction types likely to influence stewardship EDS implementation. First, EDS changes the communication patterns and practices of antimicrobial stewards in a way that improves efficiency but decreases vital social interaction with prescribers to facilitate behavior change. Second, there is a gap between what stewards envision for EDS and that which is possible to build in a timely manner by hospital information technology specialists. As a result, there is often a months- to years-long delay from proposal to implementation, which negatively affects intervention acceptance. Third, prescribers expressed great enthusiasm for stewardship EDS that would simplify their workload, allow them to complete important work tasks, and save time. They strongly objected to stewardship EDS that was disruptive without a compelling purpose or did not integrate smoothly with pre-existing technology infrastructure. Fourth, physician prescribers attributed social and emotional meaning to stewardship EDS, suggesting that these tools can undermine professional authority, autonomy, and confidence. Conclusions: Implementing stewardship EDS in a way that improves the use of antimicrobials while minimizing unintended negative consequences requires attention to the interplay between new EDS and an organization’s existing workflow, culture, social interactions and technologies. Implementing EDS in stewardship will require attention to these domains to realize the full potential of these tools and to avoid negative unintended consequences.
To determine the effect of an electronic medical record (EMR) nudge at reducing total and inappropriate orders testing for hospital-onset Clostridioides difficile infection (HO-CDI).
An interrupted time series analysis of HO-CDI orders 2 years before and 2 years after the implementation of an EMR intervention designed to reduce inappropriate HO-CDI testing. Orders for C. difficile testing were considered inappropriate if the patient had received a laxative or stool softener in the previous 24 hours.
Four hospitals in an academic healthcare network.
All patients with a C. difficile order after hospital day 3.
Orders for C. difficile testing in patients administered a laxative or stool softener in <24 hours triggered an EMR alert defaulting to cancellation of the order (“nudge”).
Of the 17,694 HO-CDI orders, 7% were inappropriate (8% prentervention vs 6% postintervention; P < .001). Monthly HO-CDI orders decreased by 21% postintervention (level-change rate ratio [RR], 0.79; 95% confidence interval [CI], 0.73–0.86), and the rate continued to decrease (postintervention trend change RR, 0.99; 95% CI, 0.98–1.00). The intervention was not associated with a level change in inappropriate HO-CDI orders (RR, 0.80; 95% CI, 0.61–1.05), but the postintervention inappropriate order rate decreased over time (RR, 0.95; 95% CI, 0.93–0.97).
An EMR nudge to minimize inappropriate ordering for C. difficile was effective at reducing HO-CDI orders, and likely contributed to decreasing the inappropriate HO-CDI order rate after the intervention.
Healthcare personnel (HCP) were recruited to provide serum samples, which were tested for antibodies against Ebola or Lassa virus to evaluate for asymptomatic seroconversion.
From 2014 to 2016, 4 patients with Ebola virus disease (EVD) and 1 patient with Lassa fever (LF) were treated in the Serious Communicable Diseases Unit (SCDU) at Emory University Hospital. Strict infection control and clinical biosafety practices were implemented to prevent nosocomial transmission of EVD or LF to HCP.
All personnel who entered the SCDU who were required to measure their temperatures and complete a symptom questionnaire twice daily were eligible.
No employee developed symptomatic EVD or LF. EVD and LF antibody studies were performed on sera samples from 42 HCP. The 6 participants who had received investigational vaccination with a chimpanzee adenovirus type 3 vectored Ebola glycoprotein vaccine had high antibody titers to Ebola glycoprotein, but none had a response to Ebola nucleoprotein or VP40, or a response to LF antigens.
Patients infected with filoviruses and arenaviruses can be managed successfully without causing occupation-related symptomatic or asymptomatic infections. Meticulous attention to infection control and clinical biosafety practices by highly motivated, trained staff is critical to the safe care of patients with an infection from a special pathogen.
OBJECTIVES/SPECIFIC AIMS: To describe the epidemiology of patients with carbapenem-resistant Enterobacteriaceae (CRE) bacteriuria in metropolitan Atlanta, GA and to identify risk factors associated with progression to an invasive CRE infection. We hypothesize that having an indwelling urinary catheter increases the risk of progression. METHODS/STUDY POPULATION: The Georgia Emerging Infections Program (EIP) performs active population- and laboratory-based surveillance to identify CRE isolated from a sterile site (e.g. blood) or urine among patients who reside in the 8-county metropolitan Atlanta area (population ~4 million). The Georgia EIP performs a chart review of each case to extract data on demographics, culture location, resistance patterns, healthcare exposures, and other underlying risk factors. We used a retrospective cohort study design to include all Georgia EIP cases with Escherichia coli, Klebsiella pneumoniae, Klebsiella oxytoca, Enterobacter cloacae, or Klebsiella (formerly Enterobacter) aerogenes, adapting the current EIP definition of resistance to only include isolates resistant to meropenem, imipenem or doripenem (minimum inhibitory concentration ≥ 4) first identified in a urine culture from 8/1/2011 to 7/31/2017. Patients with CRE identified in a sterile site culture prior to a urine culture will be excluded. Within this cohort, we will identify which patients had a subsequent similar CRE isolate identified from a sterile site between one day and one year after the original urine culture was identified (termed “progression”). CRE isolates will be defined as similar if they are the same species and have the same carbapenem susceptibility pattern. Univariable analyses using T-tests or other nonparametric tests for continuous variables, and Chi-square tests (or Fisher’s exact tests as appropriate) for categorical variables will compare patient demographics, comorbidities and presence of invasive devices including urinary catheters between patients who had progression to an invasive infection and those who did not have progression. Covariates with a p-value of < 0.2 will be eligible for inclusion in the multivariable logistic regression model with progression to invasive infection as the primary outcome. All statistical analyses will be done in SAS 9.4. RESULTS/ANTICIPATED RESULTS: From 8/1/2011 to 7/31/2017 we have preliminarily identified 546 patients with CRE first identified in urine, representing an annual incidence rate of 1.1 cases per 100,000 population. Most cases were K. pneumoniae (352, 64%), followed by E. coli (117, 21%), E. cloacae (48, 9%), K. aerogenes (18, 3%), and K. oxytoca (11, 2%). The mean patient age was 64 +/− 18 years and the majority (308, 56%) were female. Clinical characterization through chart review was available for 507 patients. The majority of the patients were black (301, 59%), followed by white (166, 33%), Asian (12, 2%), and other or unknown race (28, 6%). 466 (92%) patients had at least one underlying comorbid condition with a median Charlson Comorbidity Index of 3 (IQR 1-5). 460 (91%) infections were considered healthcare-associated (366 community-onset and 94 hospital-onset), while 44 (9%) were community-associated. 279 (55%) patients had a urinary catheter within the two days prior to the CRE culture. The analysis of patients who progress to an invasive CRE infection, including the results of the univariable and multivariable analyses assessing risk factors for progression is in progress and will be reported in the future. DISCUSSION/SIGNIFICANCE OF IMPACT: In metropolitan Atlanta, the annual incidence of CRE first isolated in urine was estimated to be 1.1 cases per 100,000 population between 2011 and 2017, with the majority of the cases being K. pneumoniae. Most patients had prior healthcare exposure and more than 50% of the patients had a urinary catheter. Our anticipated results will identify risk factors associated with progression from CRE bacteriuria to an invasive infection with a specific focus on having a urinary catheter, as this is a potentially modifiable characteristic that could be a target of future interventions.
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