bluuebunny/crossref_metadata_2025 huggingface dataset:
Patient and Community Perspectives on Antibiotics and Antimicrobial Resistance: Fertile Grounds for Antimicrobial Stewardship
Authors: Baffoe-Bonnie Anthony , Swann Mandy , Gottschalk Carter , Brewer Brent , Everson Nathan
Published: September 2024

Background: Antimicrobial resistance is a serious public health threat. Overuse of antibiotics leads to the development and spread of antibiotic resistant pathogens. Antibiotics are also responsible for a high percentage of emergency department visits for adverse drug events. Despite this, ambulatory and urgent care providers often cite patient expectations as a reason for inappropriate antibiotic prescribing practices. We investigated patient and community understanding of antibiotics and antimicrobial resistance to inform how they can be engaged as partners in combating antimicrobial resistance in our southwestern Virginia community. Methods: From July to September 2023, we conducted an online survey of patients and community members within the footprint of a large healthcare system in Southwest Virginia. Electronic medical records were used to randomly select and directly email the survey link to a representative sample of ambulatory patients who met criteria. Respondents were also recruited through the health system’s social media channels and through posters with quick response (QR) codes in outpatient offices. The survey used Likert scales and multiple-choice questions to understand experiences with and perceptions about antibiotics and antimicrobial resistance. We conducted a descriptive analysis of survey responses. Results: In total, 2,021 individuals completed the survey. Nearly 16% of respondents agreed with the statement “antibiotics can kill viruses” and almost 12% more were unsure. Thirty percent of respondents either agreed with or were unsure about the statement “antibiotics work on most coughs and colds”. When asked more directly about antimicrobial resistance, almost a quarter (25%) of respondents agreed with or were unsure about the statement “there is no connection between taking antibiotics and the development of resistant bacteria”. Responding to questions about possible negative effects of antibiotics, over 9% disagreed with the statement “antibiotics can kill the 'good' bacteria that normally live on the skin and in the gut” and another 19% were unsure. Similarly, over 20% disagreed with or were unsure about the statement “bacteria that do not respond to antibiotics could infect me or my family”. Reflecting on their own providers, nearly 83% of respondents trusted their doctor’s or nurse’s advice about antibiotic necessity. Conclusions: There are opportunities for patient and community engagement around antibiotic effectiveness for common viral illnesses and about the negative effects of overuse of antibiotics. Our data suggests most patients trust their providers as it relates to antibiotic prescribing and may be receptive to discussions and strategies that promote antimicrobial stewardship.
Outcomes in Patients with Untreated Versus Treated Asymptomatic Bacteriuria within 5 Veterans Affairs Facilities
Authors: Davis Kelly , Bennett Jessica , Kaucher Angela , Jarred Bowden , DeJarnett Brittany , Fannin Garrett , Johnson Morgan , Mitchell Anna , Osborne Colby , Powers Caroline , Williams Caroline , Williams Dana , Scheerenberger Hans
Published: September 2024

Background: Asymptomatic bacteriuria (ASB) is often treated with antibiotics despite recommendations against screening for and treating ASB in most populations. Some providers cite concern for progression of ASB to a symptomatic urinary tract infection (UTI) as the jultification for antibiotic use. While the 2019 Infectious Diseases Society of America (IDSA) ASB guidelines refute this concern, most evidence is derived from studies done in females, potentially limiting external validity. The purpose of this study is to compare the outcomes of patients with ASB who received antibiotic treatment versus those who did not in a primarily male population. Methods: This is a multi-center, retrospective, cohort study conducted by the 5 sites within the Veterans Affairs MidSouth Healthcare Network. Patients with a positive urine culture (defined as cultures with a colony forming unit count >100,000) collected from January 1, 2021 through December 31, 2021 were identified. ASB was determined via chart review using pre-determined criteria (positive culture in the absence of reported or documented signs or symptoms attributable to UTI as defined by the 2019 IDSA ASB guidelines). Additional data collected included antibiotic use, clinic visits and hospital admissions related to UTI or sepsis from a UTI. The primary outcome was the comparison of UTI incidence at 30 days, 6 months, and 1 year in those untreated versus treated with antibiotics. Secondary outcomes included a comparison of admissions with sepsis from UTI and adverse drug reactions (ADRs) between the cohorts. Continuous data were analyzed using a Student’s t-test. Discrete data were analyzed using either a Chi-squared or Fisher’s exact test. Results: The study population was primarily elderly (73 years, range 27-99 years) and male (79.7%). Of the 281 patients with ASB, 127 (45.2%) and 154 (54.8%) were untreated and treated, respectively. The incidence of UTI was 3% versus 1% (p = 0.41) at 30 days, 10% versus 12% (p = 0.61) at 6 months and 11% versus 12% (p = 0.94) at 12 months in the untreated and treated cohorts, respectively. There was no difference in admissions for UTI, sepsis from UTI or ADRs at 30 days. Conclusion: This study found no difference in the development of symptomatic UTI in veterans with untreated ASB compared to those treated with antibiotics. These findings align with current ASB guideline recommendations and support avoidance of unnecessary antibiotic use in the veteran population.
Impact of Stewardship Pharmacist Driven MRSA Nasal Surveillance and De-escalation of Anti-MRSA Therapy
Authors: Dillon Jessica , Abrantes-Figueiredo Jessica , Wiskirchen Dora , Vita Domenic
Published: September 2024

Background: Intravenous vancomycin is commonly used as initial empiric coverage for pneumonia but is often unnecessary. MRSA nasal surveillance cultures (MRSA nasal swab) have been highlighted in recent literature and the 2019 IDSA Pneumonia Treatment Guidelines as a tool to avoid unnecessary MRSA coverage in pneumonia. A negative MRSA nasal swab can be utilized by clinicians to de-escalate anti-MRSA therapies for pneumonia. The purpose of this study is to determine if implementing stewardship pharmacist driven MRSA nasal surveillance increases use of the test and reduces the inappropriate use of vancomycin for MRSA coverage in patients with pneumonia. Method: This study was a retrospective chart review and was approved by the Trinity Health of New England Institutional Review Board. For this initiative, a stewardship pharmacist evaluated all patients receiving vancomycin for anti-MRSA therapy at Saint Francis Hospital and Medical Center in Hartford, CT. If the patient’s indication was pneumonia and a MRSA nasal swab had not been ordered, the pharmacist contacted the patient’s provider and requested an order for it. Upon receipt of a negative MRSA nasal swab result, the pharmacist recommended discontinuation of vancomycin to the provider if appropriate. Outcomes from the first four weeks of the pharmacist-driven initiative (April 10, 2023 to May 5, 2023) were compared to the four weeks prior to the initiative (March 13, 2023 to April 7, 2023) as a control group. The primary outcome of this study was percentage of patients who received a MRSA nasal swab. Secondary outcomes included percentage of patients who had vancomycin appropriately de-escalated based on MRSA nasal swab results and mean length of vancomycin therapy. Result: 116 patients met inclusion criteria: 61 in the control group and 55 in the intervention group. Percentage of swabs ordered increased from 36.1% (22/61) without pharmacist intervention to 80.0% (44/55) with pharmacist intervention (p < 0 .0001). There were also increased rates of vancomycin de-escalation in patients with pharmacist intervention, with 58.2% (32/55) of patients in the intervention group having vancomycin discontinued following a negative MRSA swab compared to 19.7% (12/61) in the control group (p < 0 .0001). Conclusion: The results suggest implementing a pharmacist driven MRSA nasal surveillance program into practice could increase the number of MRSA nasal swabs ordered and in turn promote more timely de-escalation of vancomycin in patients with pneumonia. The results from this study can be used to support the wide-spread use of pharmacist driven MRSA nasal surveillance protocols at other institutions.
Impact of an intervention that decreased aztreonam DOT on Enterobacterales’ susceptibility to aztreonam
Authors: G Castro Jose , Jimenez Adriana , Anderson Tony , Quevedo Jennifer , Shukla Bhavarth
Published: September 2024

Background: Aztreonam (AZT) is frequently used for the treatment of Enterobacterales-related infections, particularly for patients with penicillin allergy. We aimed to analyze the impact over time of changes in AZT Days of therapy (DOTs) on AZT susceptibility from some Enterobacterales after a multifaceted intervention to improve antibiotic management at a University Hospital in Florida. Methods: The study took place at a 560-lbed academic hospital in Miami, FL. A multifaceted intervention was implemented in this hospital to improve antibiotic management of patients with reported allergies to penicillin. The intervention included use of algorithm-based guidance, education, and feedback to providers. The analysis period spans from 2018 (pre-intervention) through 2022 (post intervention); 2019 was considered the wash-out period (Figure 1). Quarterly data for AZT-DOT and percentage of resistance to AZT for Enterobacterales were collected as part of the normal operations of the antimicrobial stewardship program (ASP) using the infection control module integrated in the electronic medical record (Epic Bugsy). DOT and Enterobacterales antibiotic resistance to AZT was analyzed using linear regression in SPSS. Results: We identified a decrease in DOT AZT and percentage of AZT resistance from E. coli during the study period (Table 1). This intervention led to AZT DOT’s decrease from a quarterly average of 24 DOTs in 2018 levels to a sustained quarterly average of 4.3 DOTs for 2020 to Q2 2023 (decrease 80%) Antibiotic resistance to E. coli AZT changed from a 26.6% to 21.5% (19% decrease) (Table1). Simple linear regression identified a decrease in percentage of E. coli resistance to AZT associated with a decrease on AZT DOT (P-value 0.003), there was no association for other Enterobacterales. For each unit of decrease in AZT DOT there was 0.3% decrease in percentage of E. coli resistance to AZT (Table 2.) Conclusions: A decrease in AZT DOT during the observation period was associated with a decrease in E. coli resistance to AZT. Interventions aimed to decrease inappropriate antibiotic use are pivotal part of the fight against antimicrobial resistance; in our study we report a decrease in E. coli resistance to aztreonam related to decrease in the use of this antibiotic using education, guidance, and feedback to providers.
Greenhouse Gas Emissions Due to Unnecessary Antibiotic Prescriptions for Respiratory Diagnoses
Authors: Spivak Emily , Hersh Adam , Tobin Jessica , Lee Alexis
Published: September 2024

Background: Healthcare accounts for 8.5% of total US greenhouse gas emissions (GHGE), with US healthcare the main contributor. Yet little effort has been made to measure healthcare related GHGE. Specifically, GHGE related to unnecessary antibiotic prescriptions is unclear, and to our knowledge, no one has used estimates of GHGE of unnecessary antibiotics as an antibiotic stewardship tool. We aimed to measure GHGE from solid waste associated with unnecessary antibiotic prescriptions for respiratory conditions. Methods: We calculated emissions for an outpatient prescription including the plastic bottle, paper leaflet, and paper bag (photos) based on the weight of each item multiplied by US Environmental Protection Agency (EPA) GHGE factors. Emission factors depend on waste type and treatment method which we assumed to be landfilled. To estimate unnecessary antibiotic prescriptions for respiratory infections, visits from nine University of Utah Health Urgent Care Centers from 2019-2022 were electronically identified and included if they had an ICD-10-CM code for a respiratory diagnosis where antibiotics are not indicated. Waste emissions of the paper and plastic in an individual prescription were then multiplied by the number of unnecessary respiratory antibiotic prescriptions for designated time periods to arrive at total landfilled waste emissions. We used similar methods applied to published 2014 data from CDC to estimate national waste emissions due to unnecessary antibiotic prescriptions for respiratory infections. Finally, we used the EPA’s GHG Equivalencies Calculator to convert emissions into tangible GHGE for providers and patients. Results: A prescription has 32g of paper and 15g of plastic waste. Among 124,461 urgent care visits (Table 1) in 2019-2022, 18,531 (14.9%) received an antibiotic. This equates to 593 kg of paper waste and 278 kg of plastic waste leading to a total landfilled waste emissions of 0.479 MT CO2e/ton. Using the EPA GHG Equivalencies Calculator, this equates to driving an average gasoline-powered car 1,228 miles. There were 14,482,976 unnecessary antibiotic prescriptions (Table 2) in the US for respiratory infections in 2014. Our estimates suggest these prescriptions led to 375.109 CO2e/ton of GHGE, the same as driving 961,610 miles by an average gasoline-powered vehicle. Conclusion: Unnecessary antibiotic prescriptions are associated with substantial GHGE. This estimate demands further evaluation across diagnoses and care delivery sites, and most importantly action. Additionally, the large GHG contribution of unnecessary antibiotics should be used as a stewardship tool to highlight low-value care that is likely contributing to global climate change.
Impact of MIC Breakpoint Changes for Enterobacterales on Trends of Antibiotic Susceptibilities in An Academic Medical Center
Authors: Evans David , Winkler Marisa , Burd Eileen , Jones Ashley , Vu Trinh , Steinberg James , Jacob Jesse
Published: September 2024

Background: The Clinical & Laboratory Standards Institute (CLSI) recommends use of annual antibiograms to help guide empiric antibiotic therapy. Because CLSI periodically updates minimum inhibitory concentration (MIC) breakpoints, we assessed the impact of these updates on longitudinal trends in antibiotic susceptibility rates for Escherichia coli and Klebsiella pneumoniae at a single academic medical center in Atlanta, GA. Methods: Susceptibilities for cefepime, ceftazidime, and levofloxacin in E. coli and K. pneumoniae were extracted from hospital antibiograms from 1988 to 2022. Starting in 1995, intensive care units (ICUs) and wards had separate annual antibiograms, which we combined using weighted averages to create annual overall hospital antibiograms. After summarizing the frequency of isolates tested and susceptibilities using medians and interquartile ranges (IQR), we conducted an interrupted time series analysis using linear segmented regression models, to evaluate the level changes and trends in susceptibility, before and after CLSI MIC breakpoints were updated for ceftazidime (2010 and 2017), cefepime (2014 and 2017), and levofloxacin (2013). Results: Among 21,214 E. coli, there was a median of 291 [IQR: 104, 555] isolates tested annually. Similarly, among 8,686 K. pneumoniae isolates, the median was 125 per year (IQR: 76, 178). Prior to the MIC breakpoint changes, baseline susceptibility trends of both organisms to all 3 antibiotics significantly declined at a rate between 0.2% to 2.4% per year (Table 1). For cefepime (Figure 1), susceptibility decreased annually during 1988 – 2013 for both E. coli (-0.5%) and K. pneumoniae (-1.2%). There were no significant level changes but there were trend changes after 2018, for E. coli (+2.1%) and K. pneumoniae (– 5.5%). For ceftazidime (Figure 2), significant level changes occurred after 2010 for both organisms (E. coli: -5.7%; K. pneumoniae: -5.2%). For levofloxacin (Figure 3), the breakpoint update in 2013 lead to significant level change in susceptibility (E. coli: +8.4%; K. pneumoniae: +11.4%). Conclusion: Overall, we observed a consistent decrease in antibiotic susceptibility in E. coli and K. pneumoniae over three decades, with immediate increases in the level change of susceptibility when MIC breakpoints were changed, followed by a decreasing trend. These findings highlight the importance of longitudinal surveillance and MIC breakpoint changes to inform antimicrobial stewardship strategies.
Qualitative Evaluation of an Antimicrobial Stewardship Tele-Mentoring Program in US Rural & Critical Access Hospitals
Authors: Moore Elizabeth , MacLachlan Ellen , Martinez-Paz Natalia , Bajenov Maria , Jain Rupali , Chan Jeannie , Lynch John , Pottinger Paul , Kassamali Escobar Zahra , Bryson-Cahn Chloe
Published: September 2024

Background: The University of Washington (UW) Center for Stewardship in Medicine (CSiM) supports a tele-antimicrobial stewardship (AMS) program (TASP) using the ECHO approach (Extension for Community Healthcare Outcomes) in small, rural, and Critical Access Hospitals (primarily in the western U.S.) with education, mentoring, organizational capacity building, and a community of peers. To evaluate the continuing education (CE) component of UW-TASP ECHO, CSiM surveyed individuals receiving CE credits as part of the program. This survey was designed to track individuals’ satisfaction with the program and to assess the impact of UW-TASP ECHO on AMS in participating facilities. Methods: The CE participants’ survey was completed annually by individuals participating in UW TASP ECHO using online survey software. The survey included closed-ended and open-ended questions. Responses to open-ended questions were entered into Atlas.ti qualitative analysis software and coded iteratively according to themes that emerged. When a new code emerged partway through the coding process, earlier surveys were re-coded for the new code. Final codes were grouped into themes and sub-themes and quotes from each theme identified were summarized and attached to the theme and reported. Results: Data from three administrations of this survey were available: 2018-2019 (n=66); 2020-2021 (n=27); and 2021-2022 (n=30). These surveys were completed by a total of 95 individuals from 53 hospitals. Seven of these individuals completed a survey in each year, 14 completed a survey in two years, and 74 completed only one survey. Themes identified were COVID-19 support (including procedures and policies, being kept up-to-date, research summaries, and peer support), the antibiotic pocket guide developed by UW, strength in community, staff education, role of CSiM in developing/strengthening the AMS program at the facility, change in use of antibiotics, UW imprimatur, learning/growing as a healthcare provider, and importance for small, rural hospitals (see examples in Table 1). Conclusions: This qualitative analysis provides evidence from surveys of individuals participating in CE that UW TASP ECHO has had a meaningful impact in such domains as building a strong community among small, rural and critical access hospitals, educating staff, changing antibiotic use and providing peer support, among others.
Comparison of Medicare Claims-based Clostridioides difficile infection classification to chart review using a linked cohort
Authors: Currie Dustin , Lewis Chantal , Hatfield Kelly , Lutgring Joseph , Kazakova Sophia , Baggs James , Korhonen Lauren , Correa Maria , Goodenough Dana , Olson Danyel , Szydlowski Jill , Watkins Jasmine , Dumyati Ghinwa , Fridkin Scott , Wilson Christopher , Reddy Sujan , Guh Alice
Published: September 2024

Background: Medicare claims are frequently used to study Clostridioides difficile infection (CDI) epidemiology. Categorizing CDI based on location of onset and potential exposure is critical in understanding transmission patterns and prevention strategies. While claims data are well-suited for identifying prior healthcare utilization exposures, they lack specimen collection and diagnosis dates to assign likely location of onset. Algorithms to classify CDI onset and healthcare association using claims data have been published, but the degree of misclassification is unknown. Methods: We linked patients with laboratory-confirmed CDI reported to four Emerging Infections Program (EIP) sites from 2016-2020 to Medicare beneficiaries using residence, birth date, sex, and hospitalization and/or healthcare exposure dates. Uniquely linked patients with fee-for-service Medicare A/B coverage and complete EIP case report forms were included. Patients with a claims CDI diagnosis code within ±28 days of a positive CDI test reported to EIP were categorized as hospital-onset (HO), long-term care facility onset (LTCFO), or community-onset (CO, either healthcare facility-associated [COHCFA] or community-associated [CA]) using a previously published algorithm based on claim type, ICD-10-CM code position, and duration of hospitalization (if applicable). EIP classifies CDI into these categories using positive specimen collection date and other information from chart review (e.g. admit/discharge dates). We assessed concordance of EIP and claims case classifications using Cohen’s kappa. Results: Of 10,002 eligible EIP-identified CDI cases, 7,064 were linked to a unique beneficiary; 3,451 met Medicare A/B fee-for-service coverage inclusion criteria. Of these, 650 (19%) did not have a claims diagnosis code ±28 days of the EIP specimen collection date (Table); 48% (313/650) of those without a claims diagnosis code were categorized by EIP as CA CDI. Among those with a CDI diagnosis code, concurrence of claims-based and EIP CDI classification was 68% (κ=0.56). Concurrence was highest for HO and lowest for COHCFA CDI. A substantial number of EIP-classified CO CDIs (30%, Figure) were misclassified as HO using the claims-based algorithm; half of these had a primary ICD-10 diagnosis code of sepsis (226/454; 50%). Conclusions: Evidence of CDI in claims data was found for 81% of EIP-reported CDI cases. Medicare classification algorithms concurred with the EIP classification in 68% of cases. Discordance was most common for community-onset CDI patients, many of whom were hospitalized with a primary diagnosis of sepsis. Misclassification of CO-CDI as HO may bias findings of claims-based CDI studies.
Underlying Conditions in Community-associated Clostridioides difficile Infections in Davidson County, Tennessee
Authors: Turner Marissa , McClanahan Kristina , Thompson Frederick , Foster Zelda , Villegas Raquel
Published: September 2024

Background: Clostridioides difficile infections (CDI) are a crucial public health threat becoming a worldwide problem. In 2017, there were 223,900 incident cases and 12,800 deaths in the United States. Underlying conditions, such as diabetes mellitus (DM), put individuals at a greater risk for developing an infection. Whereas CDI was once believed to be mostly healthcare-associated, increasing evidence points to transmission in community settings (CA). We investigated characteristics of CA CDI and associations between pre-existing conditions and CA incident CDI cases using data from Tennessee’s CDI surveillance program, an active population- and laboratory-based surveillance system conducted through CDC’s Emerging Infections Program. CA incident CDI case data were downloaded from the Incident Case Management System from 2017 to 2021. Count and percentages were determined for each underlying condition, number of underlying conditions, and biological sex. Chi-square analyses determined associations between underlying conditions and sex. Statistical analyses were conducted using SAS v9.4. 2,326 CA incident CDI cases were identified from the catchment area. The case rates per 100,000 population between 2017 and 2021 were 79.7, 81.9, 73.7, 50.7, and 49.6. A total of 39% of the cases were 65 years or older. Most cases were women (64.8%). The overall prevalence for any underlying condition among CA CDI cases was 67.4%. A total of 29.4% of incident cases had one condition, 18.5% had two conditions, and 19.4% had three or more conditions. The most frequently reported pre-existing conditions was DM (22.9%) and gastrointestinal disease (21.7%). We looked at the prevalence of underlying conditions separated in men and women. Men with CA CDI were more likely to have chronic kidney disease (CKD) (19.1% vs 12.7%), DM (26.0% vs 21.2%), immunocompromised conditions (6.4% vs 3.6%), liver diseases (6.5% vs 2.8%), and plegias (1.0% vs 0.2%) than women with CA CDI. Women with CA CDI were more likely to have chronic lung diseases (17.4% vs 12.6%) and connective tissue diseases (4.9% vs 2.2%) than men with CA CDI. Although the incident CA CDI case rate in Davidson County decreased from 2018 to 2021, it remains a significant threat. In this analysis, underlying conditions in persons with CA CDI were highly prevalent. Men were more likely to have underlying conditions in general, and specifically CKD and DM, than women. Improving understanding of the prevalence of these conditions with CA CDI cases, along with their antibiotic use and community exposures, can help drive prevention strategies to mitigate CA CDI transmission.
Resetting the environmental reservoir; evaluating the impact of a new hospital building on Clostridioides difficile infection
Authors: Giberson Liam , Kelly Brendan , Tolomeo Pam , Cressman Leigh , Cowden Laura , Glaser Laurel , Ziegler Matthew
Published: September 2024

Background: Prior research has implicated contaminated surfaces in the transmission of Clostridioides difficile within the hospital. To reduce the risk of transmission, enhanced environmental hygiene is performed in rooms of patients with known C.difficile infection (CDI). We wished to evaluate the residual impact of environmental surfaces on hospital-onset CDI (HO-CDI) by comparing HO-CDI rates before and after the opening of a new 504-bed hospital building, HUP Pavilion (PAV). We hypothesized that we would observe a reduction in HO-CDI after opening of PAV due to a reduced burden of C.difficile spores in the environment. Methods: We included NHSN reported HO-CDI rates for 28 months prior and 24 months after opening of PAV. Upon opening, patients were divided between the old building (HUP) and PAV. We included all patient units before and after opening. We created hierarchical models of HO-CDI rates using Stan Hamiltonian Monte Carlo (HMC) version 2.30.1, via the “cmdstanr” and “brms” packages with a GAM smooth function by month and intervention period with default, weakly-informative priors. Results: At baseline, there was an average of approximately 20,100 patient days per month, subsequently divided between HUP and PAV (mean 10,100 and 12,100 patient days per month). After opening of PAV, we observed a reduced HO-CDI rate (mean 0.21 vs 0.31 per 1000 patient days, P=0.01). When comparing the two specific buildings after opening of PAV, there was a greater reduction noticed in the old building (HUP) as compared to the new building (PAV) (0.12 vs 0.29 per 1000 patient days) (Figure 1). The predicted contrast in HO-CDI rate (Figure 2), shows no immediate change in HO-CDI after opening, however a sustained reduction estimated at 0.1 HO-CDI events per 1000 patient days for the duration of follow-up. Conclusions: We observed a reduction in HO-CDI rates after the opening of a new hospital building. The difference in HO-CDI rates between hospital buildings after the move is likely due to the concentration of high-risk patient cohorts within this building. Our findings suggests that there remains an opportunity to reduce HO-CDI through environmental hygiene. However, it is possible that other factors beyond surface environment contributed to an observed reduction in HO-CDI, including other concurrent infection control interventions that focused on smaller populations within the hospital. In future work we will investigate the durability of this observed effect with additional analyses including patient-level risk for HO-CDI.
Breaking the Reflex: Impact in Hospital-Acquired Infection Incidence for Clostridioides difficile Infection
Authors: Sharma Mamta , Cosimi Reese , Stewart Alysia , Nicole Nomides , Sturm Lisa , Hart William , Johnson Leonard
Published: September 2024

Background: Nucleic acid amplification tests (NAAT) do not distinguish between colonization and Clostridioides difficile (C.diff) associated diarrhea. On April 5th 2023 our laboratory introduced a new C. diff testing methodology. Previously, if a C. diff screen result was negative for toxin and positive for glutamate dehydrogenase (GDH), a second confirmatory test was conducted with NAAT. This confirmatory test was removed from our testing algorithm. NAAT testing may be ordered ad hoc when clinically relevant diarrhea persists, and alternative etiologies have been excluded. We wanted to evaluate the impact of change with testing methods. Method: Retrospective review of all inpatient hospital-acquired C.diff infections reported to NHSN database from Ascension Michigan Market which comprises 14 acute care hospitals from June 2019 to August 2023. Data for C diff was analyzed every quarter. The risk adjustments used to calculate the Standardized Infection Ratios (SIRs) for C. diff infections was set at 0.48 based on CDC mean SIR established for acute care hospitals in 2022. Results: A total of 14 acute care hospitals were included from which 866 C.diff cases were reported during this period. Overall, the SIR dropped from 0.59 from June-August 2019 to 0.32 reported from March-May 2023; 45.7 % decrease. The maximum reduction in SIR was seen post intervention at 0.21 from June-August 2023 which was 78.3% below the benchmark of 0.48. (Figure) Conclusions: Strategies to optimize current laboratory tests are critical to differentiate C. diff infection from colonization. The current strategy by changing the testing method led to substantial reduction in C-diff. Diagnostic stewardship studies should ideally include outcome measures targeted to post-intervention patients to determine clinical relevance and patient safety. Optimizing test utilization remains a critical component of quality healthcare delivery. Future NHSN updated surveillance definition will require incorporating clinical decision-making into the metric; that is including a combination of any positive C-diff test plus initiation of antibiotic therapy for C-diff.

Disclosure: Reese Cosimi: Advisory Board - Abbvie
Hospital-Onset Clostridioides difficile infection in chronic kidney disease patients
Authors: Shallal Anita , Shanahan Clare , Ruby Abigail , Chami Eman , Kenney Rachel , Suleyman Geehan
Published: September 2024

Introduction: Hospital-onset Clostridioides difficile infection (HO-CDI), reported as laboratory-identified (LabID) event, is common in patients with chronic kidney disease (CKD), especially those with end-stage renal disease (ESRD), and is associated with prolonged length of hospitalization and more severe disease. CKD patients are at increased of developing CDI due to frequent antimicrobial and healthcare exposures. The objective of this study was to assess recent trends of HO-CDI in patients on a nephrology unit at our academic, tertiary care institution. Methods: Retrospective cross-sectional study of patients with HO-CDI who were hospitalized on a nephrology unit between January 2021 to December 2023. Collected variables included: demographic data, characterization of HO-CDI risk factors, infection and diagnosis (including prior history of CDI, toxin versus nucleic acid amplification test [NAAT] positivity, number of loose stools), CDI rate (defined as CDI count/patient days x1000), standardized antimicrobial administration ratio (SAAR) for high-risk for CDI antimicrobials (defined by the National Healthcare Safety Network), and infection prevention and control (IPC) practices, including hand hygiene audit rates. Results: A total of 30 HO-CDI infections were reported on the nephrology unit [Table], with 8 occurring in 2021, 5 in 2022, and 17 in 2023. The median age of patients was 70.8 (range: 37-96) years, and most patients (57%) were female. The majority of patients were admitted from home (73%), and two patients (7%) had a history of CDI in the last 6 months. Among the CDI cases, 60% were NAAT positive and toxin negative, and only 50% had >3 bowel movements (BM) within 24 hours prior to the positive test. Ten percent received promotility agents prior to testing. Most cases (77%) occurred when other CDI patients were on the unit. Hand hygiene compliance rates averaged 81% over the three-year period [Figure 1A]. Eight-four per cent of patients received antibiotics within 30 days of CDI diagnosis; SAAR was >1 for quarters 2 and 4 in 2022, and quarter 1 in 2023 [Figure 1B]. Conclusion: On our nephrology unit, patients often had < 3 BM within 24 hours of CDI diagnosis, and 60% of cases were toxin-negative, NAAT-positive, suggesting possible C. difficile colonization, rather than true infection. In addition, an elevated SAAR correlated with high CDI rates. Multicomponent interventions may be required to reduce the rates of HO-CDI in CKD patients. Opportunities include emphasis on diagnostic and antimicrobial stewardship, environmental cleaning and adherence to IPC practices, including hand hygiene.
Factors Associated with Inappropriate Urine Culture Orders in Hospitalized Patients with Indwelling Urinary Catheters
Authors: Azzam Ramez , Pierce Jacob
Published: September 2024

Background: Catheter-associated urinary tract infection (CAUTI) is among the most prevalent healthcare-associated infections. Clinical diagnosis of CAUTI and National Healthcare Safety Network (NHSN) definitions do not always align. Most patients with indwelling urinary catheters ultimately develop asymptomatic bacteriuria (ASB) due to bacterial colonization and may be misattributed as CAUTI. Urine cultures ordered on patients with ASB may lead to reporting of non-clinically significant CAUTI to NHSN. We sought to examine factors associated with ordering inappropriate urine cultures in patients with urinary catheters. Methods: All CAUTIs that were reported to the NHSN at a large academic medical center in Eastern North Carolina were evaluated from October 2021-July 2023. A logistic regression model was fit for patients treated for urinary tract infection (UTI) with the following covariates: age, sex, time of urine culture order, provider type, and days that the urinary catheter was in place. All data analysis was performed in SAS (SAS Institute Inc., SAS 9.4, Cary, NC: SAS Institute Inc., 2002-2023). Results: Table 1 demonstrates patient characteristics stratified by treatment for UTI. The analysis suggests that abnormalresults from urine cultures ordered overnight were less likely to be treated with antibiotics,and this result was statistically significant in both the adjusted and unadjusted analyses – see table 2 and 3. The model also suggests abnormal results from urine cultures ordered by housestaff and older patients were more likely to be treated for UTI, but these results were not statistically significant – see table 3. Finally, the longer a catheter was in place the less likely an abnormalurine culture was to be treated and this finding was statistically significant – see table 3. Conclusion: Cultures that did not prompt antimicrobial treatment did not impact patient care decisions and could be considered as inappropriate orders. This can result in CAUTIs reported to NHSN that were not clinically significant. Abnormal results from cultures that were ordered by the overnight team were less likely to be treated for clinical UTI and this may represent an important target for diagnostic stewardship interventions.
Does Urinary Catheter Replacement Prior To Obtaining Urine for Culture Make a Difference?
Authors: Moody Julia , Sands Kenneth , Kratzer Keetha , Blanchard Eunice , McLean Laura
Published: September 2024

Background: Indwelling urinary catheters (UCs) generate biofilm that grows over time, raising concern that after several days any culture from a UC may generate a false positive result. Whether and when to replace a UC prior to culture is controversial, with prior studies recommending anywhere from 3 to 14 days as appropriate, but with no conclusive data. We evaluated urine culture results across a large healthcare system where, beginning in 2019, some facilities adopted the practice of changing UC before collection if indwelling for 3 days or more. Method: Analysis was from nursing electronic health record documentation of UC changes and urine cultures collected on patients with indwelling UC in 2022. UC changes were defined as a stop followed by a start within 12 hours. Patient exclusion criteria included a UC other than “temporary/indwelling” and surgical procedure during the admission. Statistics applied Pearson’s Chi-squared test with Yates continuity correction using R Core Team (2023) R: A Language and Environment for Statistical Computing. Result: Total UC episodes meeting criteria was 88,347 across 152 acute care hospitals. Episodes in days was 0-3 for 65%, 4-9 for 29% and >9 for 6%. Most urine cultures were taken at 3 days (p UC Changed? Culture Negative Culture Positive No 4916 (98.8%) 61 (1.2%) Yes 588 (98.7%) 8 (1.3%) Cultures were positive at the same rate whether a UC change occurred or not at >3 days (p=0.96). No difference was found in NHSN reported CAUTI prevalence among the UC change vs. no change in the >3 day groups. Conclusion: Urine culture results do not appear to be impacted by UC change as early as 3 days. UC change without benefit may generate unnecessary costs and complications.
Analysis of CAUTIs and Projected Effect of Increasing Pyuria Threshold in Urinalysis with Reflex to Culture
Authors: Simpson Kristen , Colburn Nora , Manning Brandi , Agnello Sydney , Day Shandra
Published: September 2024

Background: Catheter-Associated Urinary Tract Infections (CAUTI) are preventable hospital acquired infections that contributes to patient morbidity, prolonged hospital stays and increased healthcare costs. Complete compliance to the CAUTI bundle is critical for preventing infection—not only reducing catheter days, but also ensuring appropriate indications are present for urine culture collection. Methods: This retrospective study included 145 patients diagnosed with CAUTI per NHSN definitions from July 1, 2020 to June 30, 2023. Data collected included laboratory data, catheter duration, catheter indication, urinalysis/culture indication and if foley was appropriately removed/changed prior to specimen collection. A urinary catheter indication order was implemented in February 2021 requiring providers to select specific criteria for catheter placement/maintenance. In July 2023, the threshold for urinalysis to reflex to culture was increased to ≥10 WBCs and this criteria was applied to these cases to estimate the effect on diagnosis of CAUTI. Results: The most common indications for urinary catheters were input and output monitoring 76 (52%) and urinary retention/obstruction 34 (23%). No indication was entered on 22 (15%) patients. No difference was seen in the number of catheters without an indication before or after the 2021 order update. Mean catheter duration was 11.5 days with a median of 7 days. The most common indications for obtaining a urine specimen were leukocytosis/fever/sepsis 91 (63%), urinary symptoms/abdominal/flank pain 13 (9%), urine appearance 6 (4%), and altered mental status 4 (3%). In 31 (21%) patients, no indication was identified. A urinalysis with reflex to culture was completed in 105 (72%) and the catheter was removed prior to culture collection in 68 (47%). Of the 127 patients with a urinalysis and culture, 11 had 0-5 WBCs, 16 had 6-9 WBCs, 15 had 10-20 WBCs and 85 had >20 WBCs. Using the new pyuria criteria for urinalysis to reflex to culture, 27 (19%) CAUTIs could have been avoided. Conclusion: Review of CAUTI cases identified opportunities for improving documentation and education of appropriate indications for urinary catheters and evaluation of urinary tract infection. The majority of urine cultures were obtained due to non-specific symptoms and less than 10% had specific urinary symptoms indicating need for continued education and diagnostic stewardship. Increasing the pyuria threshold needed to reflex to culture has the potential to significantly reduce CAUTIs but additional education is needed to ensure catheters are changed prior culture collection and specimens are only sent when signs and symptoms of urinary tract infection are present.
Inter-rater agreement of CAUTI (catheter-associated urinary tract infections) diagnosis among Infectious disease physicians
Authors: Kondapi Divya , Wang James , Rincon Francisco , Paniagua Lizy , Raja Mohammed , Shukla Bhavarth , Gershengorn Hayley
Published: September 2024

Background: CAUTIs constitute forty percent of nosocomial infections, yet their direct link with mortality remains debated. In 2009, NHSN estimated the economic burden of CAUTIs in the U.S. to be over $340 million. Limited data exist on inter-physician concordance in diagnosing CAUTIs, especially in patients with abnormal genitourinary (GU) anatomy. Our study assessed inter-provider variability in diagnosing CAUTI in 50 such patients, including those meeting NHSN(National healthcare safety network) criteria. Methods: We included a random set of 50 adults (18+) with abnormal GU anatomy admitted to the University of Miami hospitals from January 2018 to November 2021 who had a urinary foley catheter and at least one positive urine culture during their hospitalization. Three Infectious disease fellows and three board-certified Infectious disease physicians independently reviewed each patient’s chart, classifying them as having or not having a CAUTI. Inter-physician reliability was assessed using kappa statistics. Results: Our findings highlight substantial variation in clinician-determined CAUTI incidence among the 50 patients with abnormal GU anatomy, ranging from 8% to 32% (Figures 2,3). Inter-rater agreement on CAUTI diagnosis was generally poor (Kappa Hollenbeak CS, et al. The attributable cost of catheter-associated urinary tract infections in the United States: A systematic review. Am J Infect Control. 2018 Jul;46(7):751-757. Trautner BW, et al. Development and validation of an algorithm to recalibrate mental models and reduce diagnostic errors associated with catheter-associated bacteriuria. BMC Med Inform Decis Mak. 2013 Apr 15;13:48. Gafary M, et al. Catheter Associated Urinary Tract Infections (CAUTI) in Bladder Cancer Patients Post Cystectomy With a Neobladder, Open Forum Infectious Diseases, Volume 2, Issue suppl_1, December 2015, 293.
The Mechanics, Art, and Value of Central Line Stewardship
Authors: Gutowski Jennifer , Laguio-Vila Maryrose , Razzouk Gaby , Job Anil , Reynolds Chris , Duxbury Elizabeth , Kelly Cunningham , Nasar Farhad , Lesho Emil
Published: September 2024

Background: Central venous catheter (CVC) utilization and central-line associated bloodstream infection (CLABSI) have increased nationwide. Busy providers can easily overlook the recommended practice of daily assessment of the ongoing indication for CVC. Prospective audit and feedback (PAF) is widely used and the gold standard for antibiotic stewardship programs (ASP), but reports involving PAF for device use are scarce. Therefore, we decided to evaluate the usefulness and feasibility of PAF for reducing device utilization and ultimately CLABSI rates at our 528-bed tertiary care hospital. Methods: A PAF-based Central Line Stewardship (CLS) initiative was launched in February 2023, with a team of hospitalists, infectious diseases physicians, health informatics, vascular access nurses, and infection preventionists. On business days, CVC line-lists were exported from the electronic medical record (EMR), into a REDCap (Research Electronic Data Capture) database for team members to evaluate, in real-time, all non-ICU CVCs in place for more >72 hours (Figures 1 and 2). For CVCs eligible for stewardship, CLS members placed Legal-approved note into the patient’s EMR, advising CVC removal or alternative IV access (Figure 3). CVCs continued to be audited until removal or patient discharge. Recommendation outcomes were tracked over the subsequent 72 hours for acceptance. Standardized Utilization Rates (SUR) and Infection Rates (SIR) were calculated and compared using the National Healthcare Safety Network. Results: Between February and August 2023, the CLS team reviewed 861 CVCs, representing 581 unique patient encounters, and made 622 recommendations. Recommendations to remove or replace the CVC represented 23.5% (146) of reviews, and 57% of these CVCs were removed within 3 days. 95% of removed lines had no adverse outcomes and did not require reinsertion. Hospital-wide CVC utilization decreased 18.7% from a SUR of 1.006 in the previous year, to 0.818 during the 7-month pilot period (p < 0 .001). In the 4 months following the pilot period, decreased CVC utilization was sustained with an SUR of 0.797. Non-ICU CLABSI SIR decreased from 1.282 in 2022 to 1.024 in 2023 (p=0.36). Average time physician required for CLS review approximated a 0.4 full-time equivalent a week. The intervention was well received, with requests for expansion to urinary catheters. Conclusion: CLS safely and significantly reduced device-utilization; directly via documentation and recommendation, and indirectly through increased awareness and the Hawthorne Effect. Examples of the “art” of CLS include when to leave a discoverable note and how to determine ongoing need for CVC in a fragile patient.
Patient First Strategies for Reducing Inequities in HAI Prevention
Authors: Stancill Lisa , Sickbert-Bennett Vavalle Emily , DiBiase Lauren
Published: September 2024

Background: Inequities in healthcare-associated infections (HAI) incidence and prevention measures are critically important to understand (Chen,2021). While evaluations are beginning to characterize these disparities by infection type (Gettler, 2023), our work expands this by characterizing disparities by prevention strategies. By better understanding how evidence-based prevention strategies are implemented at the patient level, infection preventionists and hospital epidemiologists can better design strategies that provide equitable care to all patients. Methods: Beginning January 2023, gender, race, ethnicity, spoken language, and age group fields were added to daily chlorhexidine gluconate (CHG) treatment and C. difficile test order compliance data captured via electronic medical record. In July 2023, fields on recorded race, ethnicity, and gender were added to well-established foley and vascular access real-time peer audit tools that are used by infection preventionists (IPs). Each prevention strategy variable was summarized by demographic variables and differences in compliance were measured using chi-square tests. Results: 899 vascular audits and 420 foley audits were completed by IPs between July – December 2023. In 2023, there were 114,066 opportunities for CHG Treatment and 1,991 C. difficile test orders. Missing data varied by metric but ranged from 0-60%. Statistically significant differences by race were found in 3 of 8 components (i.e., intact seal, secured catheter and absence of dependent loop) in the foley audit (p < 0 .01) and compliance with C. difficile test ordering (p < 0 .01). No differences in race were found in vascular access audits or CHG treatment. No differences in gender or ethnicity were noted in foley, vascular access audits, CHG treatment compliance, or C. difficile testing. Differences in gender and age were found in CHG treatment compliance (p < 0 .001). Conclusions: By focusing more on patient level process measures rather than only presenting stratified outcomes data, we can identify targeted opportunities for improvement in health equity before our patients develop an HAI. Further evaluations should also focus on assessing the clinical relevance of statistical findings to better inform intervention strategies. Separately, efforts are needed to improve completeness and integrity of demographic data in the electronic medical record.