bluuebunny/crossref_metadata_2025_split huggingface dataset:
Healthcare-Associated Infection Decisions of Antibiotic-Resistant Organisms: A Data Quality Review
Authors: Ellison Jennifer , Bush Kathryn , Chow Blanda , Hearn Kaitlin , Howatt Andrea , Leal Jenine , Shen Ye , Yuan Christopher 
Published: November 2020

Background: Infection Prevention and Control (IPC) for Alberta Health Services and Covenant Health in the province of Alberta, Canada conducts surveillance for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE) on all individuals admitted to acute-care and acute tertiary-care rehabilitation care facilities. Objective: The objective of this study was to determine the consistency and accuracy of infection decisions for MRSA and VRE. Methods: Surveillance cases of antibiotic-resistant organisms (AROs) collected using the provincial data entry surveillance platform between April 1, 2015, and March 31, 2017, across the province were reabstracted by infection control professionals and physicians using the NHSN infection definitions and compared to the original case severity decisions. Interrater agreement (Cohen’s ) and validity (sensitivity, specificity and predictive values) were calculated to compare the original and reabstracted infection decisions. Results: Collectively, 97% (87 of 90) of the IPC program staff and physicians who were initially invited re-abstracted 264 MRSA cases and 103 VRE cases within the review period. Provincially, 20% of the ARO cases reviewed (74 of 367) differed from the original infection decision. Among these 74 cases, 46 cases (34 MRSA and 12 VRE cases) changed from infection (original decision) to colonization (reabstracted decision) and 28 cases (21 MRSA and 7 VRE cases) changed from colonization to infection. The Cohen values for MRSA and VRE were 0.55 and 0.56, respectively, suggesting a moderate level of agreement for decisions made among IPC program staff. The sensitivity of the infection decision was higher with MRSA (86.5%) than for VRE (74.1%), meaning that there were more MRSA cases than VRE cases classified as infection in the original decision that remained infection following the review. Conclusions: Observed discordances on infection decisions were identified and may be attributed (1) to variations in the interpretation of the NHSN definitions, (2) to additional information that may have been available in the re-abstracted review compared to the original review, or (3) a difference in the information that was accessed to perform the original review compared to the reabstraction. This data-quality review provided an opportunity for IPC staff and physicians to become more familiar with infection definitions and such reviews will continue to be a regular process used to assess data quality within the IPC department.Funding: NoneDisclosures: None
Hepatitis A Virus Survival on Drug Paraphernalia
Authors: Medrzycki Magdalena , Purdy Michael A. 
Published: November 2020

Background: The ongoing hepatitis A outbreak in the United States has concerned public health authorities since March 2017. The outbreak has already spread throughout 30 states and includes primarily homeless individuals and persons who use drugs, including persons who inject drugs (PWIDs). Contaminated drug injection paraphernalia and sharing of these items are suspected to be one of multiple causes of hepatitis A virus (HAV) transmission in those populations. Methods: We used a standard plaque assay to investigate HAV infectivity. Liquid suspensions of HAV were tested to examine the effects of time and temperature on viral infectivity. We also examined HAV survival on commonly used drug paraphernalia, such as needles, syringes, cookers, tourniquets, and cotton balls/filters frequently shared among PWIDs. We investigated the effect of low pH on HAV survival using citric acid, which is frequently used by PWIDs during dose preparation. We also compared the plaque assay results with those concurrently obtained by RT-PCR to establish whether viral HAV RNA levels could be used as surrogates for plaque assay results. Results: We found that HAV suspended in PBS at room temperature was able to infect FRhk4 cells for >17 weeks. HAV remained viable in syringes and needles (ie, semidry conditions) for up to 10 weeks depending on the size of the needles and the syringe dead volume. HAV survival in dry conditions on cooker, tourniquet, and cotton balls/filter surfaces did not exceed 4 weeks. HAV retained its infectivity for >10 weeks at pH as low as 2. PCR results suggest that RNA is amplified from both infectious and noninfectious HAV. Conclusions: Our findings show that HAV can survive and remain infective in the PWID setting for 4–10 weeks depending on the type of paraphernalia examined. These findings suggest that sharing drug paraphernalia by the homeless and PWIDs can potentially facilitate the transmission of HAV within these populations. Moreover, our results confirm that the plaque assay is currently the only reliable method to determine the infectivity of HAV in vitro.Funding: NoneDisclosures: None
Impact of Critical Care Consultation Requests for Avoidable Central Venous Catheters on Medical-Surgical Units
Authors: Tirumandas Madhuri , Madaline Theresa , Weston Gregory David , Jain Ruchika , Figueredo Jamie 
Published: November 2020

Background: Although central-line–associated bloodstream infections (CLABSI) in US hospitals have improved in the last decade, ~30,100 CLABSIs occur annually.1,2 Central venous catheters (CVC) carry a high risk of infections and should be limited to appropriate clinical indications.6,7 Montefiore Medical Center, a large, urban, academic medical center in the Bronx, serves a high-risk population with multiple comobidities.8–11 Despite this, the critical care medicine (CCM) team is often consulted to place a CVC when a peripheral intravenous line (PIV) cannot be obtained by nurses or primary providers. We evaluated the volume of CCM consultation requests for avoidable CVCs and related CLABSIs. Methods: Retrospective chart review was performed for patients with CCM consultation requests for CVC placement between July and October 2019. The indication for CVC, type of catheter inserted or recommended, and NHSN data were used to identify CLABSIs. CVCs were considered avoidable if a PIV was used for the stated indication and duration of therapy, with no anatomical contraindications to PIV in nonemergencies, according to the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC).6Results: Of 229 total CCM consults, 4 (18%) requests were for CVC placement; 21 consultations (9%) were requested for avoidable CVCs. Of 40 CVC requests, 18 (45%) resulted in CVC placement by the CCM team, 4 (10%) were deferred for nonurgent PICC by interventional radiology, and 18 (45%) were deferred in favor of PIV or no IV. Indications for CVC insertion included emergent chemotherapy (n = 8, 44%) and dialysis (n = 3, 16%), vasopressors (n = 3, 16%), antibiotics (n = 2, 11%) and blood transfusion (n = 2, 11%). Of 18 CVCs, 9 (50%) were potentially avoidable: 2 short-term antibiotics and rest for nonemergent indications; 2 blood transfusions, 1 dialysis, 2 chemotherapy and 2 vasopressors. Between July and October 2019, 6 CLABSIs occurred in CVCs placed by the CCM team; in 3 of 6 CLABSI events (50%), the CVC was avoidable. Conclusions: More than half of consultation requests to the CCM team for CVCs are avoidable, and they disproportionately contribute to CLABSI events. Alternatives for intravenous access could potentially avoid 9% of CCM consultations and 50% of CLABSIs in CCM-inserted CVCs on medical-surgical wards.Funding: NoneDisclosures: None
Impact of Removal of Automatic 7-Day Stop Orders for Inpatient Antimicrobials
Authors: Adu-Gyamfi Afia , Hamilton Keith , Cressman Leigh , Lautenbach Ebbing , Dutcher Lauren 
Published: November 2020

Background: Automatic discontinuation of antimicrobial orders after a prespecified duration of therapy has been adopted as a strategy for reducing excess days of therapy (DOT) as part of antimicrobial stewardship efforts. Automatic stop orders have been shown to decrease antimicrobial DOT. However, inadvertent treatment interruptions may occur as a result, potentially contributing to adverse patient outcomes. To evaluate the effects of this practice, we examined the impact of the removal of an electronic 7-day ASO program on hospitalized patients. Methods: We performed a quasi-experimental study on inpatients in 3 acute-care academic hospitals. In the preintervention period (automatic stop orders present; January 1, 2016, to February 28, 2017), we had an electronic dashboard to identify and intervene on unintentionally missed doses. In the postintervention period (April 1, 2017, to March 31, 2018), the automatic stop orders were removed. We compared the primary outcome, DOT per 1,000 patient days (PD) per month, for patients in the automatic stop orders present and absent periods. The Wilcoxon rank-sum test was used to compare median monthly DOT/1,000 PD. Interrupted time series analysis (Prais-Winsten model) was used to compared trends in antibiotic DOT/1,000 PD and the immediate impact of the automatic stop order removal. Manual chart review on a subset of 300 patients, equally divided between the 2 periods, was performed to assess for unintentionally missed doses. Results: In the automatic stop order period, a monthly median of 644.5 antibiotic DOT/1,000 PD were administered, compared to 686.2 DOT/1,000 PD in the period without automatic stop orders (P < .001) (Fig. 1). Using interrupted time series analysis, there was a nonsignificant increase by 46.7 DOT/1,000 PD (95% CI, 40.8 to 134.3) in the month immediately following removal of automatic stop orders (P = .28) (Fig. 2). Even though the slope representing monthly change in DOT/1,000 PD increased in the period without automatic stop orders compared to the period with automatic stop orders, it was not statistically significant (P = .41). Manual chart abstraction revealed that in the period with automatic stop orders, 9 of 150 patients had 17 unintentionally missed days of therapy, whereas none (of 150 patients) in the period without automatic stop orders did. Conclusions: Following removal of the automatic stop orders, there was an overall increase in antibiotic use, although the change in monthly trend of antibiotic use was not significantly different. Even with a dashboard to identify missed doses, there was still a risk of unintentionally missed doses in the period with automatic stop orders. Therefore, this risk should be weighed against the modest difference in antibiotic utilization garnered from automatic stop orders.Funding: NoneDisclosures: None
Measuring the Cost of Overtesting and Overdiagnosis of Clostridioides difficile Infection
Authors: Madden Gregory , Smith David , Sifri Costi 
Published: November 2020

Background:C. difficile is the leading healthcare-associated pathogen. The C. difficile real-time polymerase chain reaction (PCR) stool test, used by >70% of hospitals, is highly sensitive but cannot differentiate colonization from infection. Inappropriate C. difficile testing may result in overdiagnosis and unnecessary treatment. Healthcare costs attributed to C. difficile are substantial, but the economic burden associated with C. difficile false positives in colonized patients is poorly understood. C. difficile PCR cycle threshold (CT) is as an inverse proxy for organism burden; high CT (≥30.9) has a high (>98%) negative predictive value compared to the reference gold standard, thus is a marker of colonization. Conversely, a low CT (≤28.0) suggests high organism burden and high specificity for true infection. Methods: A propensity score matching model for cost per hospitalization was developed to determine the costs of a hospital stay associated with C. difficile and to isolate the financial impacts of both true C. difficile infection and false positives. Relevant predictors of C. difficile positivity used in the model were age, Charlson comorbidity index, white blood cell count, and creatinine. We used CT data to identify and compare 3 inpatient groups: (1) true CDI, (2) C. difficile colonization, and (3) C. difficile negative. Results: A diagnosis of C. difficile adds significantly (>$3,000) to unadjusted hospital cost compared to a negative result. Propensity-adjusted analyses demonstrated that C. difficile colonization was associated with significantly increased (median, $5,000) hospital cost whereas any positive or true diagnoses of C. difficile were not associated with increased cost. Colonized patients also had significantly higher lengths of stay (1 day) and cost per length of stay ($218 per day). Conclusions:This is the first C. difficile cost analysis to utilize PCR CT data to differentiate colonization. Surprisingly, patients with a high CT had disproportionately higher hospital costs compared to matched C. difficile–negative patients, which was not seen among patients with a low CT or with any positive result. We hypothesize that this unexpected finding may be due to misdiagnosis and mistreatment of diarrhea not caused by C. difficile or unadjusted factors associated with high cost and non–C. difficile diarrhea. In addition, the discrepantly high cost attributed to C. difficile diagnosis cited in the literature ($3,000–11,000 per hospitalized case) could be explained by the common use of administrative data to identify C. difficile cases and controls as opposed to our study, which directly linked cost data to C. difficile–positive and –negative test results.Funding: NoneDisclosures: None
Modified Veterans Health Administration Clostridioides difficile Infection (CDI) Prevention Bundle: Progress Over 8 Years Decreasing CDI Laboratory-Identified (LabID) Events at a Large Veterans Affairs Medical Center
Authors: Byers Patricia , Hunter Andrew , Young Edward J. , Almeida Sherri-Lynne , Stonecypher Karen , Chou Andrew 
Published: November 2020

Background: In March 2012, the Veterans’ Health Administration (VHA) published the Guideline for the Prevention of Clostridium difficile infection (CDI) in VHA Inpatient Acute-Care Facilities, with a goal of 30% reduction of cases within 2 years. In March 2011, this facility, along with 31 others, served as a pilot site to develop the guidelines. Methods: The CDI prevention bundle was implemented to prevent new onset CDI cases in the facility with 4 core measures: (1) environmental cleaning (EMS), (2) hand hygiene, (3) contact precautions, and (4) cultural transformation. Education was provided to EMS staff, nursing, and care providers on the CDI case definition, criteria for testing, empiric isolation for patients with diarrhea, hand hygiene, and PPE to control spread. In 2014, antimicrobial stewardship was added, and within 5 years an algorithm for isolation and testing was published. Cases were reviewed weekly using TheraDoc software and were reported monthly to the national VHA Inpatient Evaluation Center (IPEC). Isolation was communicated using a ward roster/isolation list in TheraDoc for all unit champions to consult daily. CDI cases were classified using NHSN definitions for a laboratory-identified (LabID) event, recurrent cases, and community-onset cases. Real-time case review and weekly multidisciplinary case discussions identified opportunities for improved compliance with the core measures. Results: Over an 8-year period, CDI healthcare-onset LabID events decreased by 73%. The cases decreased from 149 to 40 over the 8-year period. The infection rate decreased 70% from 16.19 per 10,000 bed days of care in FY2011 (October 2010) to 4.88 in FY2019. The incidence of community onset infections increased from 75 in FY2011 to a high of 146 in FY2018 for a rate of 8.15 to 18.17. In FY2019, there was a decrease in both LabID events and community-onset cases to lows of 40 and 102, respectively. Inappropriate testing decreased by 84% from 50 in FY2011 to 8 in FY2019. Conclusions: A multidisciplinary team approach that included support from leadership and clinical providers as well as front line staff involvement, daily rounding, and case review by infection preventionists has reduced all CDI cases over an 8-year period using the modified VHA CDI bundle. TheraDoc enabled case review, correct isolation, changes to cleaning practices, and more appropriate lab testing. The antimicrobial stewardship program that includes clinical pharmacists working daily with providers was a strong driver for change.Funding: NoneDisclosures: None
Novel Method to Detect Cardiac Device Infections by Integrating Electronic Medical Record Text with Structured Data in the Veterans Affairs Health System
Authors: Mull Hillary , Stolzmann Kelly , Shin Marlena , Kalver Emily , Schweizer Marin , Branch-Elliman Westyn 
Published: November 2020

Background: Cardiovascular implantable electronic device (CIED) infections are highly morbid, yet infection control resources dedicated to preventing them are limited. Infection surveillance in outpatient care is also challenging because there are no infection reporting mandates, and monitoring patients after discharge is difficult. Objective: Thus, we sought to develop a replicable electronic infection detection methodology that integrates text mining with structured data to expand surveillance to outpatient settings. Methods: Our methodology was developed to detect 90-day CIED infections. We tested an algorithm to accurately flag only cases with a true CIED-related infection using diagnostic and therapeutic data derived from the Veterans Affairs (VA) electronic medical record (EMR), including administrative data fields (visit and hospital stay dates, diagnoses, procedure codes), structured data fields (laboratory microbiology orders and results, pharmacy orders and dispensed name, quantity and fill dates, vital signs), and text files (clinical notes organized by date and type containing unstructured text). We evenly divided a national dataset of CIED procedures from 2016–2017 to create development and validation samples. We iteratively tested various infection flag types to estimate a model predicting a high likelihood of a true infection, defined using chart review, to test criterion validity. We then applied the model to the validation data and reviewed cases with high and low likelihood of infection to assess performance. Results: The algorithm development sample included 9,606 CIED procedures in 67 VA hospitals. Iterative testing over 381 chart reviewed cases with 47 infections produced a final model with a C-statistic of 0.95 (Table 1). We applied the model to the 9,606 CIED procedures in our validation sample and found 100 infections of the 245 cases identified by the model to have a high likelihood of infection We identified no infections among cases the model as having low likelihood. The final model included congestive heart failure and coagulopathy as comorbidities, surgical site infection diagnosis, a blood or cardiac microbiology order, and keyword hits for infection diagnosis and history of infection from clinical notes. Conclusions: Evolution of infection prevention programs to include ambulatory and procedural areas is crucial as healthcare delivery is increasingly provided outside traditional settings. Our method of algorithm development and validation for outpatient healthcare-associated infections using EMR-derived data, including text-note searching, has broad application beyond CIED infections. Furthermore, as integrated healthcare systems employ EMRs in more outpatient settings, this approach to infection surveillance could be replicated in non-VA care.Funding: NoneDisclosures: None
Parental Knowledge, Attitudes, and Practices Regarding Antibiotic Use: A Cross-Sectional Study in Bangladesh
Authors: Harun Golam Dostogir , Haider Romel , Haque Imdadul , Chowdhury Alauddin , Islam Saiful 
Published: November 2020

Background: Antibiotics play a vital role in reducing the morbidity and mortality associated with common infectious among children aged <5 years. Objective: We assessed the parental knowledge, attitudes, and practices regarding antibiotic use among a low-income urban population in Bangladesh. Methods: A cross-sectional study was conducted among the parents of 516 low-income urban children aged <5 years in Bangladesh from February 2018 to April 2019. A semi-structured questionnaire was developed and administrated to explore parental knowledge, attitudes, and practice regarding antibiotic use. A logistic regression analysis and Spearman rank-order correlation was used to compare and evaluate possible associations regarding parental KAP on antibiotic use. Results: The mean age of the participants was 26.65 years (SD, 6.38) and average monthly income was US$195.00. Most respondents (437 of 516) were women. One-third of the participants had no formal education, and 64% had only 5 years of education. We categorized the knowledge, attitudes, and practice regarding antibiotic use into 3 categories: poor, moderate, and good. More than half (52%) of these parents had poor knowledge of antibiotic use, and 32% had moderate knowledge of antibiotic use. Overall, 55% of parental attitudes were moderate and 70% of antibiotic practices were moderate. However, only 16% respondents had good knowledge, 14% had good attitudes, and 14% had good practices regarding antibiotic use for their children. The study revealed that 41% of parents thought that their child could be treated with antibiotics without advice from a qualified doctor, and 71% of parents thought that a child with flu-like symptoms got better faster if antibiotics were used. Also, 54% thought that the antibiotics could be stopped as soon as the symptoms disappeared. In this study, only 40% of parents completed the full dose of antibiotics. Monthly family income (P = .005), father’s profession (P = .003), and parents’ education were significantly associated with antibiotic use to treat the child. Conclusions: Most participants’ knowledge, attitude, and practices regarding rational antibiotic usage was very poor. Awareness campaigns and implementation of education on how to purchase, use, and sell antibiotics is crucial to optimum the use of antibiotics in Bangladesh.Funding: NoneDisclosures: None