bluuebunny/crossref_metadata_2025 huggingface dataset:
World wetlands classification: a new hierarchic hydro-ecological approach
Authors: Junk Wolfgang J.
Published: September 2024

Many different approaches to classify wetlands at regional and global levels have been proposed, but their use of different classification parameters complicates comparisons of the results. Moreover, none of the international approaches cover global wetland variety with respect to size and environmental conditions. A comparison shows that hydrology is the only parameter that can be used for a hierarchic classification on a global scale. In the approach presented herein, differentiation between coastal, inland and anthropogenic wetlands is proposed. The use of higher classification units (systems, subsystems, orders, suborders and classes) is based on hydrological parameters. Wetlands are separated into small, simply structured types treated by all classification systems, and large wetscapes that, due to their complexity, are not. However, wetscapes represent well-defined landscape units, many of which are the focus of international organizations involved in wetland protection. They have to be treated using a holistic approach given the many interactions of their ecological subunits, their role in regional economies, their targeting by legislation and their value to humans. Considering the large gaps in knowledge about wetlands at a global scale, the new approach is a powerful tool for its classification, because it is flexible enough to include additional classification units, as required. Local classification systems can eliminate higher categories, which do not occur in their regions. Classification at lower rankings (functional units, subclasses, macrohabitats) can be introduced using additional classification parameters such as vegetation, soils and water chemistry. Examples from Brazil are provided.
Real world challenges and barriers for positive airway therapy use in acute ischemic stroke patients
Authors: Pascoe Maeve , Grigg-Damberger Madeleine M , Walia Harneet , Andrews Noah , Wang Lu , Bena James , Katzan Irene , Uchino Ken , Foldvary-Schaefer Nancy
Published: September 2024

Purpose

Untreated obstructive sleep apnea (OSA) in patients with acute ischemic stroke (AIS) is associated with increased morbidity and mortality. However, diagnosing and treating OSA in AIS is challenging. We aimed to determine the feasibility of portable monitoring (PM) for diagnosis and positive airway pressure therapy for treatment of OSA in an inpatient stroke population.

Methods

We recruited inpatients with AIS from Cleveland Clinic. Those who consented underwent PM; participants with a respiratory event index (REI) ≥ 10 were offered auto-titrating positive airway pressure therapy (APAP). Ease-of-use questionnaires were completed. We summarized categorical variables using n(%) and continuous variables using mean ± SD or median [IQR].

Results

27 participants (age 59.8 ± 11.8, 51.9% female, 51.9% Black, BMI 33.4 ± 8.5) enrolled. The study ended early due to Medicare contracting that forced most patients to complete stroke rehabilitation outside the Cleveland Clinic health system. 59.3% had large vessel occlusions and 53.8% had moderate/severe disability (Modified Rankin score ≥ 2). PM was attempted in 21 participants, successful in 18. Nurses and patients rated the PM device as highly easy to use. 13 of 18 (72%) patients who had an REI ≥ 10 consented to APAP titration, but only eight (61.5%) of those 13 used APAP for more than one night, and only five (27.8%) used APAP up to 90 days with data captured for only one participant. Five required troubleshooting at titration, and only one had adherent APAP usage by objective assessment after discharge.

Conclusions

This study demonstrates the real-world challenges of assessing and treating OSA in an AIS population, highlighting the necessity for further research into timely and feasible screening and treatment.
Mathematical model of dating apps’ influence on sexually transmitted diseases spread
Authors: Lazebnik Teddy
Published: September 2024

Sexually transmitted diseases (STDs) are a group of pathogens infecting new hosts through sexual interactions. Due to its social and economic burden, multiple models have been proposed to study the spreading of pathogens. In parallel, in the ever-evolving landscape of digital social interactions, the pervasive utilization of dating apps has become a prominent facet of modern society. Despite the surge in popularity and the profound impact on relationship formation, a crucial gap in the literature persists regarding the potential ramifications of dating apps usage on the dynamics of STDs. In this paper, we address this gap by presenting a novel mathematical framework - an extended Susceptible-Infected-Susceptible (SIS) epidemiological model to elucidate the intricate interplay between dating apps engagement and the propagation of STDs. Namely, as dating apps are designed to make users revisit them and have mainly casual sexual interactions with other users, they increase the number of causal partners, which increases the overall spread of STDS. Using extensive simulation, based on real-world data, explore the effect of dating apps adoption and control on the STD spread. We show that an increased adoption of dating apps can result in an STD outbreak if not handled appropriately.
Long/post-COVID in children and adolescents: symptom onset and recovery after one year based on healthcare records in Germany
Authors: Ehm Franz , Tesch Falko , Menzer Simone , Loser Friedrich , Bechmann Lars , Vivirito Annika , Wende Danny , Batram Manuel , Buschmann Tilo , Ludwig Marion , Roessler Martin , Seifert Martin , Sarganas Margolis Giselle , Reitzle Lukas , Koenig Christina , Schulte Claudia , Ballesteros Pedro , Bassler Stefan , Bitterer Thomas , Riederer Cordula , Berner Reinhard , Scheidt-Nave Christa , Schmitt Jochen , Toepfner Nicole
Published: September 2024

Purpose

Evidence on the incidence and persistence of post-acute sequelae of COVID-19 (PASC) among children and adolescents is still limited.

Methods

In this retrospective cohort study, 59,339 children and adolescents with laboratory-confirmed COVID-19 in 2020 and 170,940 matched controls were followed until 2021-09-30 using German routine healthcare data. Incidence rate differences (ΔIR) and ratios (IRR) of 96 potential PASC were estimated using Poisson regression. Analyses were stratified according to age (0–11, 12–17 years), and sex. At the individual level, persistence of diagnoses in patients with onset symptoms was tracked starting from the first quarter post-infection.

Results

At 0–3 month follow-up, children and adolescents with a previous SARS-CoV-2 infection showed a 34% increased risk of adverse health outcome, and approximately 6% suffered from PASC in association with COVID-19. The attributable risk was higher among adolescents (≥ 12 years) than among children. For most common symptoms, IRRs largely persisted at 9–12 month follow-up. IRR were highest for rare conditions strongly associated with COVID-19, particularly inflammatory conditions among children 0–11 years, and chronic fatigue and respiratory insufficiency among adolescents. Tracking of diagnoses at the individual level revealed similar rates in the decline of symptoms among COVID-19 and control cohorts, generally leaving less than 10% of the patients with persistent diagnoses after 12 months.

Conclusion

Although very few patients presented symptoms for longer than 12 months, excess morbidity among children and, particularly, adolescents with a history of COVID-19 means a relevant burden for pediatric care.
Bedeutungen von Freiheiten und Sicherheiten
Authors: Döbler Marie-Kristin
Published: September 2024

Wie selbstverständlich sprechen wir von Freiheit und Sicherheit. Was aber meinen wir damit? Versuchen wir diese Frage zu beantworten, wird schnell klar: Sowohl in der theoretischen Literatur als auch in der empirischen Wirklichkeit gibt es ganz viele verschiedene Verständnisse. Vor diesem Hintergrund wird im Beitrag die zweiteilige These vertreten, dass es notwendig ist, Ebenen, Erscheinungsformen und Bedeutungen von Freiheit und Sicherheit zu unterscheiden und vielfältige Wechselverhältnisse von Freiheiten und Sicherheiten zu berücksichtigen. Dies wird mit einem Fokus auf die Mikroebene ausgehend von 17 Interviews mit Eltern von (fast) erwachsenen Kindern exemplarisch aufgezeigt. Die Analyse der Schilderungen elterlicher Lebensläufe demonstriert sowohl eine Vielfalt als auch Dynamik der Bedeutungen von Freiheit und Sicherheit. Sie lässt ebenfalls erkennen, dass unterschiedliche Freiheiten bzw. Sicherheiten gleichzeitig anwachsen und schrumpfen können. Dabei variieren erlebbare Freiheiten und Sicherheiten eher graduell als binär zwischen den Zuständen frei/unfrei bzw. sicher/unsicher. Zusätzlich veranschaulichen in den Interviews rekonstruierbare floskelhafte Formulierungen, Verweise auf Allgemeinwissen und Muster, dass ‚Freiheit‘ und ‚Sicherheit‘ soziokulturell präformiert werden. So erfüllen Verweise auf Freiheiten und Sicherheiten auch zahlreiche kommunikative Funktionen, z. B. bei der Identitätskonstruktion oder der Selbstpositionierung, und lassen wiederholt bestimmte Bedeutungsunterschiede zwischen Müttern und Vätern feststellen. All das unterstreicht, dass es nicht nur epistemologisch sinnvoll ist, im Plural von Freiheiten bzw. Sicherheiten zu sprechen, sondern dass auch deren empirisch-ontologische Pluralität und Kontextsensitivität anzuerkennen sind.
Yemilab, a new underground laboratory in Korea
Authors: Kim Yeongduk , Lee Hyun Su
Published: September 2024

In September 2022, Yemilab, a new underground laboratory, was finally completed in Jeongseon, Gangwon Province, South Korea. Situated at a depth of 1000 m, it boasts an exclusive experimental area of 3000 m2. Currently, preparations are in progress for the AMoRE-II experiment, which aims to investigate neutrinoless double beta decay, as well as for the COSINE-100 upgrade (COSINE-100U), a direct dark matter detection experiment. Both experiments are scheduled to commence in the second quarter of 2024 at Yemilab. Furthermore, the facility encompasses a cylindrical pit, approximately 6300 m3 in volume, designed to serve as a multipurpose laboratory. This laboratory will facilitate next-generation experiments focusing on neutrinos, dark matter, and related areas of research. This article presents a detailed overview of Yemilab’s construction, infrastructure, and its pivotal physics programs.
Modeling and simulation study of end around taxiway operation of Shanghai Hongqiao Airport
Authors: Chen Z. , Zhao Z. , Cheng B.
Published: September 2024

With the rapid expansion of the aviation industry, an increasing number of Close Spaced Parallel Runway (CSPR) airports are either planning or constructing End Around Taxiways (EAT) to alleviate field operation pressures and enhance safety. Taking Shanghai Hongqiao Airport’s typical CSPR EAT configuration as a case study, this research integrates the airport’s current operational status with the anticipated requirements for future structural renovations and increased flight volumes. Various operational scenarios are established, and simulation research on optimising EAT operations is conducted in advance. The simulation study proceeds as follows: first, an AirTOP simulation model is constructed based on Hongqiao Airport’s actual operational construction. Subsequently, leveraging existing operational scenarios, five simulation scenarios are devised by activating EATs at the departure and approach ends of the eastern zone. The merits and drawbacks of these scenarios are thoroughly analysed. The findings indicate that, with escalating flight volumes, the utilisation of EAT for larger aircraft can curtail their holding duration by nearly 8 min, consequently reducing overall arrival holding duration by 6 min. Departures from gates proximate to T1 experience a 3-min reduction in holding duration through the adoption of EAT at the approach end. Despite an increase in taxi distance due to a higher proportion of aircraft taxiing around, the overall taxi time is diminished. Activating EATs at the departure and approach ends of the eastern zone effectively mitigates the adverse effects of heightened flight volumes on field operational efficiency.
Antimicrobial Use in Veterans Affairs Community Living Centers, 2015 - 2019
Authors: Dalton Christian , Willson Tina , Wilson Brigid , Bej Taissa , El Chakhtoura Nadim , Song Sunah , Hicks Oteshia , Kowal Corinne , Jones Makoto , Handler Steven , Jump Robin , Stevens Vanessa
Published: September 2024

Background: Optimizing antimicrobial use (AU) among post-acute and long-term care (PALTC) residents is fundamental to reducing the morbidity and mortality associated with multidrug-resistant organism (MDROs), as well as unintended social consequences related to infection prevention. Data on AU in PALTC settings remains limited. The U.S. Department of Veteran Affairs (VA) provides PALTC to over 23,000 residents at 134 community living centers (CLCs) across the United States annually. Here, we describe AU in VA CLCs, assessing both class and length of therapy. Methods: Monthly AU between January 1, 2015 and December 31, 2019 was extracted from the VA Corporate Data Warehouse across 134 VA CLCs. Antimicrobials and administration routes were based on the National Healthcare Safety Network AU Option protocol for hospitals. Rates of AU were measured as the days of therapy (DOT) per 1,000 resident-days. An antimicrobial course was defined as the same drug and route administered to the same resident with a gap of ≤ three days between administrations. Course duration was measured in days. AU Rates were measured as the days of therapy (DOT) per 1,000 resident-days. Results: The most common class of antimicrobial course administered during the study period was beta-lactam/beta-lactamase inhibitor combinations (15%) followed by fluroquinolones (14%), extended-spectrum cephalosporins (12%) and glycopeptides (11%; Figure 1). Neuraminidase inhibitors had the longest median (IQR) course duration (10 (IQR 8) days), followed by tetracyclines (8 (IQR 8) days), and then folate pathway inhibitors, nitrofurans and 1st/2nd generation cephalosporins (7 (IQR 7) days). Overall, 60% of antimicrobial courses were administered orally, with fluroquinolones the most frequently administered orally (20%). From 2015 – 2019, the annual rate of total antimicrobial use across VA CLCs decreased slightly from 213.6 to 202.5 DOT/1,000 resident-days. During the 5-year study period, fluroquinolone use decreased from 27.47 to 13.36 DOTs/1,000 resident-days. First and 2nd generation cephalosporin use remained relatively stable, but 3rd or greater generation cephalosporin use increased from 14.70 to 19.21 DOTs/1,000 resident-days (Figure 2). Conclusion: The marked decrease in the use of fluoroquinolones at VA CLCs from 2015-2019 is similar to patterns observed for VA hospitals and for non-VA PALTC facilities. The overall use of antibacterial agents at VA CLCs decreased slightly during the study period, but other broad-spectrum agents such as 3rd or greater generation cephalosporins increased over the same period. The strategies used to decrease fluroquinolone use may have application for other antibiotic classes, both in VA and non-VA PALTC settings.

Disclosure: Robin Jump: Research support to my institution from Merck and Pfizer; Advisory boards for Pfizer
Evaluation of Predictors Associated with Slow Clinical Response with Extension of Outpatient Parenteral Antimicrobial Therapy
Authors: McSweeney Kristen , Liu Fang Yu , Erdil Rachel , Alsoubani Majd , Vindenes Tine , Doron Shira , Foong Kap Sum
Published: September 2024

Background: Outpatient parenteral antimicrobial therapy (OPAT) provides a safe and effective alternative to prolonged hospitalization for patients with infectious diseases requiring elongated antimicrobial therapy. One study found that 35.6% of OPAT episodes met the composite definition for treatment failure, with unplanned extension of OPAT as the most common reason for treatment failure. Our study sought to identify factors predicting higher likelihood of extension of OPAT due to slow clinical response to treatment and determine how therapy extension relates to complications. Method: This retrospective cohort study included all patients aged ≥18 years discharged on OPAT between April 2022 and October 2022. Demographic, treatment, outcome, and complications data were extracted through chart review. The primary outcome was the proportion and predictors of OPAT extension due to slow clinical response to treatment. The secondary outcomes were OPAT complication rate, 30-day ED visit and 30-day readmission rates related to OPAT complications. We used univariable and multivariable logistic regression models for the primary outcome of slow clinical response requiring OPAT extension. Variables with p < 0.1 in the univariable analyses were included in the multivariable model. Result: 231 patients received OPAT during the six-month study. Among them, 40 (17.3%) patients required an extension of therapy. In univariable analysis, patients who had slow clinical response requiring extension of OPAT were more likely to have intraabdominal infection (odds ratio [OR], 2.435; 95% confidence interval[CI], 1.053–5.628), receipt of metronidazole (OR, 3.729; 95% CI, 1.413–9.842), and were more likely to be followed up through office visit (OR, 5.033; 95%CI, 1.164–21.759) or combination of office visit and telemedicine (OR, 2.223; 95%CI 1.041–4.747). Other variable comparisons are detailed in Figure 1. In the multivariable regression analysis, the independent predictor associated with extended of OPAT was follow-up via office visit (adjusted OR, 4.630; 95% CI, 1.024-20.694). Rates of complications related to intravenous access and antibiotic were similar between patients with and without extension; 15% vs. 11% (p=0.430) and 7.5% vs. 7.3% (p=1.000), respectively. There were no significant differences in 30-day ED visits and readmission rates between the 2 groups: 7.5% vs. 5.8%(p=0.715) and 12.5% vs. 7.3% (p=0.338). Conclusion: Our study highlights patient’s office visit follow-up is associated with the OPAT extension due to slow clinical response. However, extended therapy did not result in a significant increase in complications or hospital readmissions. These findings suggest the importance of careful patient selection and monitoring for OPAT, potentially guiding more efficient and targeted healthcare practices.
Cefadroxil is an option for Gram-positive bone and joint infections in adults
Authors: Kluthe Kennedy , Johnson Rachael , Cortes-Penfield Nicolas
Published: September 2024

Background: Oral antimicrobial therapy for osteoarticular infections in adults is increasingly adopted; however, the preponderance of published data and experience with oral antibiotics involves agents such as fluoroquinolones, trimethoprim-sulfamethoxazole, and clindamycin. Data supporting the use of narrower-spectrum, stewardship-friendly oral antibiotics with favorable toxicities profiles (e.g. cefadroxil) are needed. Methods: We report a case series of adults who underwent surgery for monomicrobial Gram-positive osteomyelitis, native joint septic arthritis (NJSA), prosthetic joint infection (PJI), or other orthopedic hardware infection at our institution from January 2019 through January 2022 and who subsequently received at least two weeks of oral cefadroxil. We excluded patients who had polymicrobial infection or curative amputation, or who received cefadroxil only as suppressive antibiotic therapy (SAT). Our primary outcome of interest was treatment success during followup, defined as freedom from death, unplanned surgery for infection, or readmission for worsening infection. Results: We identified 22 patients who received cefadroxil for primary treatment of osteoarticular infection. The mean age was 57.6 years, mean weight 98.6 kg, 68% were male, and none had peripheral vascular disease. Infections included PJI in 12, NJSA in 8, osteomyelitis in 7, and other hardware infections in 5; some patients had multiple infectious syndromes. Methicillin-susceptible Staphylococcus aureus (MSSA) was the most common pathogen (73%), followed by streptococci (18%), other methicillin-susceptible staphylococci (14%), and Cutibacterium acnes (5%). Half of patients received 120kg who had device infections with MSSA, two of which were managed with implant retention, suggesting pharmacokinetic/pharmacodynamic factors and biofilm burden could influence treatment outcome. Limitations of this study include its small sample size, noncomparative nature, lengthy initial intravenous antibiotic durations, and limited durations of followup. These data suggest cefadroxil merits investigation for adult osteoarticular infection in larger comparative (and ideally, prospective randomized) studies.
Evaluating the Clinical Impact of Species-Level Identification in Coagulase-Negative Staphylococci Positive Blood Cultures
Authors: Hamdan Ahmad , Andujar-Vazquez Gabriela , Campion Maureen , Poonawala Husain , Cebulla Catherine , Alsoubani Majd
Published: September 2024

Background: Coagulase-negative staphylococci (CoNS) are often considered contaminants when isolated from blood cultures. While criteria exist to distinguish true bacteremia from contamination (Table 1), clinical judgement is often necessary. Clinical microbiology laboratories have traditionally identified CoNS to the species level only if present in multiple cultures. There have been concerns that blood cultures positive for rare or less familiar CoNS species might be misinterpreted as true bacteremia. Tufts Medical Center (TMC) clinical microbiology laboratory started reporting all CoNS to the species level in January 2023. We studied the impact of species-level identification of CoNS on clinically relevant outcomes following this change. Methods: The study evaluated inpatients at TMC aged ≥ 18 years with CoNS isolated from blood cultures between July 2022 and June 2023. The primary outcome was the difference in anti-staphylococcal antibiotic utilization between the pre- and post-intervention groups. Secondary outcomes included differences in true bacteremia diagnosis, length of hospital stay, and mortality between the two groups. We also compared the performance of Souvenir’s criteria with clinical judgement at distinguishing contamination from true bacteremia. A total of 100 patients were included in the pre- and post-intervention groups to detect an estimated effect size of 15% with a power of 81%. Results: Most patients were male, White, and English speaking (Table 2). No differences were found between the two groups in terms of infectious disease consultation frequency, blood culture collection department, or the presence of central venous catheters (Table 2). Staphylococcus epidermidis was the predominant CoNS in the post-intervention group. Blood cultures were repeated before and after starting antibiotics in 24% and 74% (pre-intervention) and 18% and 84% (post-intervention) of cases, respectively. Anti-staphylococcus antibiotic use was the same in both groups (82%). The median antibiotic therapy duration was 4.5 days pre- vs 3 days post-intervention (p =0.39). There were no differences in hospital length of stay or mortality between the two groups (Table 3). The clinical diagnosis of true bacteremia was established in 28% of cases in the pre- vs 25% in the post-intervention group (p= 0.63). Compared to clinical judgement, Souvenir’s true bacteremia criteria demonstrated a sensitivity of 80.3%, negative PV of 91.9%, and positive PV of 55.2%. Conclusions: Species-level identification of CoNS positive blood cultures did not impact antibiotic utilization, diagnosis of true bacteremia, length of hospital stay, or mortality. Further studies with larger cohorts and prospective designs are needed to validate these findings and assess the long-term implications in patients.
Antimicrobial use among under-five hospitalized children in Bangladesh: Findings from a Point Prevalence Survey
Authors: Harun Md. Golam Dostogir , Chowdhury ABM Alauddin , Sumon Shariful Amin
Published: September 2024

Background: The use of antibiotics and the occurrence of antimicrobial resistance in Bangladesh are very high. Inappropriate use of antibiotics among hospitalized children has contributed to a high rise in antimicrobial resistance in Bangladesh. Data on the rational use of antibiotics in Bangladeshi hospitals are limited. This study documented current antimicrobial usage among children under five in selected tertiary hospitals in Bangladesh. Methods: From August to September 2022, we conducted a point prevalence survey in four tertiary hospitals in Bangladesh. We used the World Health Organization’s Point Prevalence Survey (PPS) methods and guidelines to conduct the study. Study participants were hospitalized under the age of five years children, and we collected information from the pediatric and neonatal wards of each hospital. Antibiotic-suggesting shapes were analyzed according to WHO AWaRe metrics and Anatomical Therapeutic Chemical (ATC) Classification. Results: The assessment included 189 children under the age of five, with the majority (78.8%, 149/189) being under one year children. Approximately three-fourths (75.1%) of children had peripheral vascular catheters following admission. Overall, 86.2% (163/189) of children were given antibiotics after being admitted to the hospital, with infants receiving the most (81.0%, 132/163). The majority of antibiotics were administered by parents (84.7%). Antibiotics from the Watch Group were most commonly prescribed (73.0%, 119/163), followed by a combination of the Watch and Access Groups (23.3%) to treat the children. Ceftriaxone (63.8%), Meropenem (16.0%), and Ceftazidime/Amikacin (8.0%) were the most regularly prescribed antibiotics. Young children (< 1 year) were more likely to get antibiotics (AOR: 3.54, p-value: 0.003) than the other children under the age of five. Conclusion: The data showed that most children received empirical antibiotics during hospitalization, and overuse of broad-spectrum Watch group antibiotics was common practice in hospital settings. Developing and implementing antibiotic use guidelines is critical to limit the inappropriate use of antibiotics for young children
Blood Culture Contamination Mitigation: Sustaining Success and Stewardship Systemwide
Authors: Povroznik Mark
Published: September 2024

Background: False-positive blood cultures compromise care; extended stays, Clostridioides difficile risk increases and renal woes tagged to antibiotic alms contribute to the doubling of patient in-hospital mortality that is observed relative to true negative diagnostic results. False-positive affiliated central line-associated bloodstream infection reports can further obfuscate the quality of care provided. Between personnel performance pressures, laboratory resource losses and the risk for financial penalty under Value-Based Purchasing and Hospital-Acquired Condition Reduction Programs (Centers for Medicare & Medicaid Services), it becomes difficult to brush aside the burden of a non-zero blood culture contamination rate. Following unsuccessful and unsustainable endeavors that included educational exercise and waste tube employment, initial-specimen diversion devices designed to shift performance burdens from technicians to technology were co-opted in an effort to secure reliable blood culture contamination rate reductions. Methods: A 3.6% blood culture contamination rate was observed systemwide prior to intervention, which began in 2020. Among seventeen facilities that share a data system, twelve co-opted initial-specimen diversion device technology as the evidence-based anchor to a trifurcate intervention strategy that included value analysis and cultural curation. Results: The 2023 systemwide blood culture contamination rate was 1.95%; down from 2.8% in 2022 and 3.2% in 2021. The average cost per false-positive event was $2,111, with intervention amounting to systemwide savings of $4.1 million in 2023 as approximately 1,920 patients avoided false-positive incidents. Critical to year-over-year systemwide uptick in adoption of interventive technology was consistent and near real-time communication to caretakers regarding outcomes. Conclusion: The sustained success of the multifactorial solution showcased herein stems from the coupling of an evidence-based action with an ongoing assessment of value and communication channels carefully constructed to celebrate and perpetuate value observed. Layered uncertainties often cloud the crux of a multifactorial solution to a complex conundrum; for many decades the literature-supported solution to high blood culture contamination rates was to educate every person involved in every possible way. Only recently, following recommended practice revisions endorsed by the Clinical and Laboratory Standards Institute and Centers for Disease Control and Prevention, did it become apparent nationwide that education alone was insufficient; some contaminant pathways persist without meticulously mechanical closure. Antimicrobial stewardship requires the respectful removal of adaptable pressures from microorganisms, but the inverse is equally important; by setting an ambitious systemwide blood culture contamination rate target of 1% or less, it is hoped that all facilities involved herein respond to this pressure with optimism, introspection and innovation.
Risk Factors Predicting Complication of OPAT in an Academic Center: A Retrospective Cohort Study
Authors: Yu Liu Fang , McSweeney Kristen , Erdil Rachel , Alsoubani Majd , Vindenes Tine , Doron Shira , Sum Foong Kap
Published: September 2024

Background: While Outpatient Parenteral Antibiotic Therapy (OPAT) offers patient convenience and reduced healthcare costs, its increasing utilization has brought various complications to light, including antibiotics-related and line-related OPAT complications. In a large prospective study, 18% of the patients experienced adverse drug events. Another study showed 8.45% of patients had vascular complications. Our study aims to identify clinical predictors associated with OPAT complications. Identifying predictors for suboptimal OPAT outcomes provides an opportunity to intervene, thereby minimizing the risk of OPAT-related complications. Method: We conducted a retrospective cohort study at Tufts Medical Center of all adult patients aged ≥18 years discharged on OPAT from April 2022 to October 2022. Demographic, treatment, outcome, and complications data were extracted through chart review. The primary outcome was the proportion and predictors of OPAT complications. The secondary outcomes were OPAT completion rate, 30-day ED visit, and 30-day readmission rates related to OPAT complications. We used univariable and multivariable analyses using logistic regression models for the predictors of OPAT complications. Variables with p5 (OR, 0.281, 95% CI 0.101–0.784), but they were more likely to have received two antibiotics (OR, 2.265; 95% CI 1.155-4.442). However, no significant independent predictor OPAT complications was identified in multivariable regression analysis (Figure 2). OPAT completion rates were lower in patients with complications (59.1% versus 75.4%). The 30-day ED visit and 30-day readmission rates were significantly higher in the complication group (31.8% vs. 0 and 34.1% vs. 2.1%, respectively). Conclusion: Our study highlights the significant difference in treatment completion rates and higher incidence of ED visits and readmissions rates among those with OPAT complications. Although specific independent predictor was not identified, the association with multiple antibiotic therapies and telemedicine follow-ups suggests areas for further investigation.
Identifying Higher-Volume Antibiotic Outpatient Prescribers Using Medicare Part D Prescription Data — Arizona, 2021
Authors: Vajrala Swathi , Bhattarai Rachana , Pham Tho , Naderi Mandana , Sanchez Celine , Kim Elizabeth , Komatsu Kenneth
Published: September 2024

Background: Increased antibiotic resistance is a rising global health problem that can result from overprescribing and misusing antibiotics. The impact of antibiotic overprescribing is significant, particularly among the older adult population due to increased adverse reactions. The objective of this study is to identify higher volume antibiotic outpatient prescribers and their antibiotic prescription rates by region and provider specialties in Arizona. Methods: Publicly available data from the Center for Medicare and Medicaid Services Part D Prescriber database during 2021 was analyzed. Those prescribers who had beneficiaries and antibiotic claims of fewer than 11 were excluded from the analysis. Higher-volume prescribers were identified by estimating the providers who prescribed the highest 10th percentile of antibiotic volume. The cumulative percentage of antibiotic prescriptions and prescriber’s antibiotic volume per 1000 beneficiaries (prescribing rate) were compared between the higher volume prescribers and lower volume prescribers by the EMS region and specialty. Median prescribing rates among prescribers were compared using the Wilcoxon rank-sum test. All analyses were performed using SAS (version 9.4; SAS Institute, NC). Results: The number of Arizona prescribers included in the dataset during 2021 was 27,124. After excluding prescribers with fewer than 11 antibiotic prescriptions, 14,410 prescribers were included in the analysis. These providers prescribed a total of 1,095,559 antibiotic prescriptions, with a median of 45 antibiotic prescriptions per prescriber. Thirty-nine percent of antibiotic prescriptions were written by the higher volume prescribers and prescribed a median of 236 antibiotic prescriptions. Higher-volume prescribers had a 52% higher median antibiotic prescribing rate compared with lower-volume prescribers (600 versus 396 prescriptions per 1,000 beneficiaries) (p < 0.01). The median antibiotic prescribing rate among higher volume prescribers was highest in the central region (602 antibiotic prescriptions per 1,000 beneficiaries) compared with other regions (581 prescriptions per 1,000 beneficiaries in the north region) (p < 0.01). The top two specialties that higher volume prescribers practiced were family practice and nurse practitioners. Antibiotic prescribing rates of higher-volume prescribers were highest among dentists (1,118 prescriptions per 1,000 beneficiaries).
Pilot of a Bowel Habit Assessment Tool to Enable Early Identification of C. diff Infection
Authors: Kon Shelley , Christine Gunter , Hough Heidi , Craig Randi , Lane Ashley , Bessesen Mary
Published: September 2024

Background: Gastrointestinal conditions are common in hospitalized patients. Decreased mobility, dietary changes, medications and their underlying illness may alter patients’ bowel movements. It’s important for health care providers to be aware of patient’s bowel habits, especially for early identification of Clostridiodies difficile infection (CDI). Prior research has shown that patient modesty may be a barrier to discussing bowel habits with nurses and providers. This can lead to delay in diagnosis of CDI, lack of timely isolation and possible misclassification of community onset CDI cases as hospital onset (HO-CDI). Methods: A Bowel Habits Assessment Tool (BHAT) was developed to assist health care providers in learning skills to assess and document patient bowel habits accurately. The tool provides a structured approach to help clinicians gather relevant information, identify abnormalities, and promote effective communication with patients. The tool was developed by an infectious disease physician and modeled on existing tools utilized to take a sexual history. A team of infectious disease physicians, nurses and a gastroenterologist reviewed the tool and provided feedback. See Table 1. The tool was introduced as a pilot program at a 180 bed academically affiliated Veterans Affairs Hospital. Micro educational sessions were held to provide education about the importance of a bowel habit history, introduce the tool and teach its use in clinical care. The teaching sessions were led by an Infectious Disease physician and a nurse infection preventionist. An anonymous pre and post survey employing a 5-point Likert scale was administered to participants. All participation was voluntary. This project was reviewed and approved as a Quality Improvement by the VA Research Office, Eastern Colorado Health Care System. Results: Twenty nine healthcare personnel participated in the pilot. Participants included nurses (13), resident physicians (13), medical students (2) and nursing assistants (1). 59% of participants stated that they strongly agree with the statement “I am comfortable discussing patient’s bowel habits” on the pre-survey. (Question 1). This increased to 73% after the BHAT educational session. The mean difference between pre and post survey responses for question one was 0.45 (CI 0.08761 to 0.8089, p= 0.0167). All participants found the BHAT related to their work and useful, with 41% strongly agreeing and 52% somewhat agreeing that the BHAT was useful. See figure 1: Survey Responses. Conclusions: The effectiveness of a bowel habit assessment tool was demonstrated using a pre and post survey. BHAT improved clinicians comfort level discussing patient’s bowel habits.
Assessing Clinical Outcomes for C. diff Polymerase Chain Reaction (PCR)-positive, Enzyme Immunoassay (EIA)-negative Patients
Authors: Jurasinski Philip , Wu Xiangni , Fatima Ifrah , Erasani Greeshma , Dyer Barbara , Bennett Nicholas , Boyd Sarah
Published: September 2024

Background: In August 2021, Saint Luke’s Health System (SLHS) transitioned Clostridioides difficile (C. diff.) testing from polymerase chain reaction (PCR)-only to two-step enzyme immunoassay (EIA) reflex following PCR+ for suspected C. diff. infection. Uncertainty in patient management may arise when PCR and EIA testing differ. Previous studies suggested that disease severity varies when a patient’s results demonstrate PCR+ and EIA- due to possible colonization. Clinicians may not treat if diarrhea self-resolves, patients remain stable, or alternate causes of diarrhea exist. We compared clinical outcomes of patients who received treatment to those who did not. Methods: This was a retrospective cross-sectional study from August 2021-August 2023 in a multi-site, integrated health system, comparing 181 inpatients with PCR+/EIA- C. diff. test results stratified by no treatment (0-48 hours of C. diff. targeted treatment), partial treatment (2-9 days), or full treatment (10+ days). The primary outcome was length of stay. Secondary outcomes were readmission rates, need for colectomy, intensive care unit (ICU) admission, and diarrhea resolution on day of discharge. Results: Of the 181 patients, 144 received full treatment, 17 had partial, and 20 had no treatment. Baseline characteristics were similar between groups. No significant difference was found for length of stay or any secondary outcomes (Table 1). Table 2 provides a subgroup of patients who received no treatment vs those receiving partial or full treatment. Conclusion: In this study, treatment exposure did not affect clinical outcomes for patients with PCR+/EIA- results, though sample sizes may limit generalizability. Further research is warranted regarding the clinical approach to PCR+/EIA-
Impact of Clostridioides difficile Reporting on Antimicrobial Therapy Days Directed at Treatment of C. difficile Infections
Authors: Plauche Ardath , Septimus Edward , Thomas Jamie
Published: September 2024

Background: Previous studies have found that solely relying on molecular testing is likely to result in the overdiagnosis and overtreatment of C. difficile infections (CDI). Comparable outcomes have been demonstrated in patients with a positive molecular test (C. difficile PCR) result and a negative toxin immunoassay (C. difficile toxin) compared to patients without CDI by either testing Method: In 2021 Memorial Hermann Healthcare System converted from C. difficile PCR testing only to C. difficile PCR testing with reflex to C. difficile toxin if positive. A previous internal audit revealed that despite this change in testing, patients who were C. difficile PCR positive and C. difficile toxin negative were still receiving treatment. This study aimed to evaluate the impact of C. difficile reporting on the total days of therapy directed at the treatment of CDI of an 11-hospital health care system in patients who testing C. difficile PCR positive/C. difficile toxin negative. Methods: Pre-post, multicenter, retrospective, observational study conducted from January 1, 2023 through March 31, 2023 (pre-intervention) and July 1, 2023 through September 31, 2023 (post-intervention) which included hospitalized adult patients with a C. difficile test ordered within the study period. Intervention included a change in reporting of C. difficile PCR positive/C. difficile toxin negative results to display a laboratory comment. The comment notifies providers of the positive C. difficile PCR result while highlighting this probably reflects colonization with C. difficile as the C. difficile toxin is negative and treatment is rarely indicated. Results: In total, 989 C. difficile PCR were order in the pre-intervention cohort compared to 1009 in post-intervention. The overall rate of patients that received therapy directed at CDI decreased from 14% to 10% after the implementation of reporting change. Total days of therapy (DOT) also decreased by 29% from 482 to 342. Days of therapy that were administered to patients with C. difficile PCR positive/negative C. difficile toxin test decreased from 183 to 91. Conclusions: Adjusting the reporting of C. difficile results led to an overall numerical decrease of antimicrobial DOT directed at CDI treatment. In particular, among patients with a positive C. difficile PCR/C. difficile toxin negative test a 50% reduction in DOT was observed. Further data are required to assess the overall clinical impact of adjusting CDI reporting methods.
Audit and Feedback to Ordering Providers to Reduce Inappropriate C. difficile Testing and Hospital Onset C. difficile Rate
Authors: Martin Elise , Kung Vanessa , Feigel Jody , Nagaro Kristin , Buehrle Deanna
Published: September 2024

Background: Inappropriate Clostridioides difficile (C. difficile) laboratory testing is common in hospitals and leads to over diagnosis, unnecessary treatment, and elevated hospital onset C. difficile infection (HO-CDI) metrics. Diagnostic stewardship is essential to avoid inappropriate testing, but limited data exists on optional interventions. Methods: A diagnostic stewardship intervention targeting CDI testing comprised of education and prospective audit with feedback was performed a VA facility (inpatient, outpatient, and long-term care units). Education on appropriate indications for CDI testing was provided in pre-intervention (9/2022 to 5/2023) and intervention periods (6/2023 to 12/2023). During the intervention period, all CDI tests (positive or negative) were audited after completion in real-time by an Infectious Diseases physician and feedback was given to ordering providers and/or their supervising physician (if trainee) for all tests not meeting an appropriate indication. Appropriate indication was defined as ≥3 liquid stools in 24 hours or symptoms of fulminant disease. Testing was considered inappropriate if no clinical symptoms, patient received laxatives within 48 hours, test was performed for test-of-cure or within 7 days of a prior test with no clinical change, or delayed testing in patients with diarrhea on admission. The rate of HO-CDI per 10,000 bed days of care (BDOC) per LabID event was compared during the pre-intervention and intervention periods, and ordering appropriateness was compared for all tests and hospital onset tests before (3/2023-5/2023) and after (6/2023-12/2023) feedback was performed. Results: After starting audit and feedback, HO-CDI rate decreased from 3.92 per 10,000 BDOC to 0.99 per 10,000 BDOC (p=0.03). HO-CDI rate among tests that were inappropriate was 2.19 and 0.80 per 10,000 BDOC during the pre-intervention and intervention periods, respectively (p=0.40). Average overall tests per month decreased from 37.8 to 28.1 after the intervention. Rate of all inappropriate tests decreased from 16.25 to 7.96 per 10,000 BDOC (p=0.04) and rate of hospital onset inappropriate tests trended toward decrease from 9.29 to 4.77 tests per 10,000 BDOC (p=0.07). The most common reasons for inappropriate testing were < 3 episodes of diarrhea in 24 hours (54% pre-intervention, 65% intervention) and laxative use (57% pre-intervention, 45% intervention). No cases of delayed testing leading to worsened disease were identified during the intervention. Cost savings for decreased tests were estimated at $150-300 per month. Conclusion: An intervention comprised of education and real-time audit and feedback of all CDI tests obtained at a VA facility resulted in decreased inappropriate testing and reduced the rate of HO-CDI.
Longitudinal Follow Up of Patients Colonized with Clostridioides difficile: a Retrospective Cohort Study
Authors: Bilodeau-Harnois Bianca , Longtin Yves , Parkes Leighanne
Published: September 2024

Background: Patients colonized with Clostridioides difficile are at risk of transmitting C. difficile to other patients, and of developing C. difficile infection (CDI). Known risk factors for carriage include previous hospitalization, gastric acid suppression and previous CDI. Data regarding duration of carriage and its predictors are lacking but could be useful to better understand the natural evolution of carriage and better estimate the likelihood of transmission or progression to CDI. Methods: We performed a retrospective cohort study of C. difficile colonized patients with > = 1 admission to a tertiary academic institution between November 2013 and January 2017. Colonization status was determined upon hospital admission by detection of TcdB gene by polymerase chain reaction on a rectal screening swab, as part of a systematic screening program. Overall duration of carriage and predictors of prolonged carriage were explored using Kaplan-Meier methods and Cox regression. Results: There were 134 patients, who after having a positive initial screening test (and therefore identified as colonized with C. difficile), had subsequent testing. The median age was 77 years (IQR, 66 to 85), and 53.6% of the patients were female. After hospital discharge, 26 (19.4%) colonized patients progressed to CDI. Mean duration of follow up was 269 days, with a median of 179 days. Median duration of carriage was 211 days, (95% confidence interval (CI) [157, 264]). Predictors associated with decreased duration of C. difficile colonization included younger age (HR per unit decrease (year), 1.013; 95% CI, 1.025 to 1.001; p=0.03), and receipt of antibiotics in the 3 months prior to first admission (mean days to clearance of patients with and without recent antibiotic use, 252 days vs 372 days, respectively; HR, 1.55; 95% CI, 1.01 to 2.36; p < 0 .04). By contrast, the presence of comorbidities (e.g. heart failure, diabetes, cancer, and chronic kidney disease), the use of proton-pump inhibitors (PPIs), the receipt of antibiotics during the first admission, and the duration of first hospitalization were not associated with significant differences in duration of carriage. Conclusion: This study is the largest cohort of C. difficile carriers with longitudinal follow up of their colonization status. It highlights the extended duration of carrier status especially in older patients and identifies predictors of prolonged carriage. Further studies are needed to understand the underlying relationship with the predictors identified in this study.