Obesity in Refugees post-resettlement in a high-income country: a meta-analysis

BACKGROUND

Refugees have a high prevalence of obesity post resettlement, but few studies have compared their risk of obesity to those of the host population. We systematically investigated the association between refugee status and obesity after resettlement in a high-income nation.

METHODS

We searched PubMed, Embase, OpenGrey and bibliographies of retrieved articles, with no date, location, and language restrictions, for observational studies assessing obesity rates in resettled refugees compared to the host population.

RESULTS

Nine studies were analyzed. We found no evidence of increased risk of obesity among refugees compared to the host population, with significant heterogeneity across studies. However, the risk of obesity among refugee men were significantly lower than the host population.

DISCUSSION

The heterogeneity between studies calls for more high-quality research to examine the risk of obesity among refugees compared to the host population in high-income countries. This will enable results to be pooled to provide more decisive evidence about obesity trends among refugees post migration in a high-income nation.

Implementing nasal povidone-iodine decolonization to reduce infections in hemodialysis units: a qualitative assessment

BACKGROUND

A substantial proportion of patients undergoing hemodialysis carry Staphylococcus aureus in their noses, and carriers are at increased risk of S. aureus bloodstream infections. Our pragmatic clinical trial implemented nasal povidone-iodine (PVI) decolonization for the prevention of bloodstream infections in the novel setting of hemodialysis units.

OBJECTIVE

We aimed to identify pragmatic strategies for implementing PVI decolonization among patients in outpatient hemodialysis units.

DESIGN

Qualitative descriptive study.

SETTING

Outpatient hemodialysis units affiliated with five US academic medical centers. Units varied in size, patient demographics, and geographic location.

INTERVIEWEES

Sixty-six interviewees including nurses, hemodialysis technicians, research coordinators, and other personnel.

METHODS

We conducted interviews with personnel affiliated with all five academic medical centers and conducted thematic analysis of transcripts.

RESULTS

Hemodialysis units had varied success with patient recruitment, but interviewees reported that patients and healthcare personnel (HCP) found PVI decolonization acceptable and feasible. Leadership support, HCP engagement, and tailored patient-focused tools or strategies facilitated patient engagement and PVI implementation. Interviewees reported both patients and HCP sometimes underestimated patients' infection risks and experienced infection-prevention fatigue. Other HCP barriers included limited staffing and poor staff engagement. Patient barriers included high health burdens, language barriers, memory issues, and lack of social support.

CONCLUSION

Our qualitative study suggests that PVI decolonization would be acceptable to patients and clinical personnel, and implementation is feasible for outpatient hemodialysis units. Hemodialysis units could facilitate implementation by engaging unit leaders, patients and personnel, and developing education for patients about their infection risk.

Propensity Score-Weighted Analysis of Postoperative Infection in Patients With and Without Preoperative Urine Culture

Importance

Although recent guidelines recommend against performance of preoperative urine culture before nongenitourinary surgery, many clinicians still order preoperative urine cultures and prescribe antibiotics for treatment of asymptomatic bacteriuria in an effort to reduce infection risk.

Objective

To assess the association between preoperative urine culture testing and postoperative urinary tract infection (UTI) or surgical site infection (SSI), independent of baseline patient characteristics or type of surgery.

Design, Setting, and Participants

This cohort study analyzed surgical procedures performed from January 1, 2017, to December 31, 2019, at any of 112 US Department of Veterans Affairs (VA) medical centers. The cohort comprised VA enrollees who underwent major elective noncardiac, nonurological operations. Machine learning and inverse probability of treatment weighting (IPTW) were used to balance the characteristics between those who did and did not undergo a urine culture. Data analyses were performed between January 2023 and January 2024.

Exposures

Performance of urine culture within 30 days prior to surgery.

Main Outcomes and Measures

The 2 main outcomes were UTI and SSI occurring within 30 days after surgery. Weighted logistic regression was used to estimate odds ratios (ORs) for postoperative infection based on treatment status.

Results

A total of 250 389 VA enrollees who underwent 288 858 surgical procedures were included, with 88.9% (256 753) of surgical procedures received by males and 48.9% (141 340) received by patients 65 years or older. Baseline characteristics were well balanced among treatment groups after applying IPTW weights. Preoperative urine culture was performed for 10.5% of surgical procedures (30 384 of 288 858). The IPTW analysis found that preoperative urine culture was not associated with SSI (adjusted OR [AOR], 0.99; 95% CI, 0.90-1.10) or postoperative UTI (AOR, 1.18; 95% CI, 0.98-1.40). In analyses limited to orthopedic surgery and neurosurgery as a proxy for prosthetic implants, the adjusted risks for UTI and SSI were also not associated with preoperative urine culture performance.

Conclusions and Relevance

This cohort study found no association between performance of a preoperative urine culture and lower risk of postoperative UTI or SSI. The results support the deimplementation of urine cultures and associated antibiotic treatment prior to surgery, even when using prosthetic implants.

Comparative effectiveness of daptomycin versus vancomycin among patients with methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections: A systematic literature review and meta-analysis

BACKGROUND

In the treatment of methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections (BSIs), vancomycin stands as the prevalent therapeutic agent. Daptomycin remains an alternative antibiotic to treat MRSA BSIs in cases where vancomycin proves ineffective. However, studies have conflicted on whether daptomycin is more effective than vancomycin among patients with MRSA BSI.

OBJECTIVE

To compare the effectiveness of daptomycin and vancomycin for the prevention of mortality among adult patients with MRSA BSI.

METHODS

Systematic searches of databases were performed, including Embase, PubMed, Web of Science, and Cochrane Library. The Newcastle Ottawa Scale (NOS) and Revised Cochrane risk-of-bias tool for randomized trials (RoB 2) were used to assess the quality of individual observational and randomized control studies, respectively. Pooled odd ratios were calculated using random effects models.

RESULTS

Twenty studies were included based on a priori set inclusion and exclusion criteria. Daptomycin treatment was associated with non-significant lower mortality odds, compared to vancomycin treatment (OR = 0.81; 95% CI, 0.62, 1.06). Sub-analyses based on the time patients were switched from another anti-MRSA treatment to daptomycin demonstrated that switching to daptomycin within 3 or 5 days was significantly associated with 55% and 45% decreased odds of all-cause mortality, respectively. However, switching to daptomycin any time after five days of treatment was not significantly associated with lower odds of mortality. Stratified analysis based on vancomycin minimum inhibitory concentration (MIC) revealed that daptomycin treatment among patients infected with MRSA strains with MIC≥1 mg/L was significantly associated with 40% lower odds of mortality compared to vancomycin treatment.

CONCLUSION

Compared with vancomycin, an early switch from vancomycin to daptomycin was significantly associated with lower odds of mortality. In contrast, switching to daptomycin at any time only showed a trend towards reduced mortality, with a non-significant association. Therefore, the efficacy of early daptomycin use over vancomycin against mortality among MRSA BSIs patients may add evidence to the existing literature in support of switching to daptomycin early over remaining on vancomycin. More randomized and prospective studies are needed to assess this association.

Intravenous Diltiazem Versus Metoprolol in Acute Rate Control of Atrial Fibrillation/Flutter and Rapid Ventricular Response: A Meta-Analysis of Randomized and Observational Studies

BACKGROUND

Atrial fibrillation (AF) and/or atrial flutter (AFL) with rapid ventricular response (RVR) is a condition that often requires urgent treatment. Although guidelines have recommendations regarding chronic rate control therapy, recommendations on the best choice for acute heart rate (HR) control in RVR are unclear.

METHODS

A systematic search across multiple databases was performed for studies evaluating the outcome of HR control (defined as HR less than 110 bpm and/or 20% decrease from baseline HR). Included studies evaluated AF and/or AFL with RVR in a hospital setting, with direct comparison between intravenous (IV) diltiazem and metoprolol and excluded cardiac surgery and catheter ablation patients. Hypotension (defined as systolic blood pressure less than 90 mmHg) was measured as a secondary outcome. Two authors performed full-text article review and extracted data, with a third author mediating disagreements. Random effects models utilizing inverse variance weighting were used to calculate odds ratios (OR) and 95% confidence intervals (CI). Heterogeneity was assessed using the I2 test.

RESULTS

A total of 563 unique titles were identified through the systematic search, of which 16 studies (7 randomized and 9 observational) were included. In our primary analysis of HR control by study type, IV diltiazem was found to be more effective than IV metoprolol for HR control in randomized trials (OR 4.75, 95% CI 2.50-9.04 with I2 = 14%); however, this was not found for observational studies (OR 1.26, 95% CI 0.89-1.80 with I2 = 55%). In an analysis of observational studies, there were no significant differences between the two drugs in odds of hypotension (OR 1.12, 95% CI 0.51-2.45 with I2 = 18%).

CONCLUSION

While there was a trend toward improved HR control with IV diltiazem compared with IV metoprolol in randomized trials, this was not seen in observational studies, and there was no observed difference in hypotension between the two drugs.

Implementing strategies to prevent infections in acute-care settings

This document introduces and explains common implementation concepts and frameworks relevant to healthcare epidemiology and infection prevention and control and can serve as a stand-alone guide or be paired with the "SHEA/IDSA/APIC Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals: 2022 Updates," which contain technical implementation guidance for specific healthcare-associated infections. This Compendium article focuses on broad behavioral and socio-adaptive concepts and suggests ways that infection prevention and control teams, healthcare epidemiologists, infection preventionists, and specialty groups may utilize them to deliver high-quality care. Implementation concepts, frameworks, and models can help bridge the "knowing-doing" gap, a term used to describe why practices in healthcare may diverge from those recommended according to evidence. It aims to guide the reader to think about implementation and to find resources suited for a specific setting and circumstances by describing strategies for implementation, including determinants and measurement, as well as the conceptual models and frameworks: 4Es, Behavior Change Wheel, CUSP, European and Mixed Methods, Getting to Outcomes, Model for Improvement, RE-AIM, REP, and Theoretical Domains.

Implementation of a Prevention Bundle to Decrease Rates of Staphylococcus aureus Surgical Site Infection at 11 Veterans Affairs Hospitals

Importance

While current evidence has demonstrated a surgical site infection (SSI) prevention bundle consisting of preoperative Staphylococcus aureus screening, nasal and skin decolonization, and use of appropriate perioperative antibiotic based on screening results can decrease rates of SSI caused by S aureus, it is well known that interventions may need to be modified to address facility-level factors.

Objective

To assess the association between implementation of an SSI prevention bundle allowing for facility discretion regarding specific component interventions and S aureus deep incisional or organ space SSI rates.

Design, Setting, and Participants

This quality improvement study was conducted among all patients who underwent coronary artery bypass grafting, cardiac valve replacement, or total joint arthroplasty (TJA) at 11 Veterans Administration hospitals. Implementation of the bundle was on a rolling basis with the earliest implementation occurring in April 2012 and the latest implementation occurring in July 2017. Data were collected from January 2007 to March 2018 and analyzed from October 2020 to June 2023.

Interventions

Nasal screening for S aureus; nasal decolonization of S aureus carriers; chlorhexidine bathing; and appropriate perioperative antibiotic prophylaxis according to S aureus carrier status. Facility discretion regarding how to implement the bundle components was allowed.

Main Outcomes and Measures

The primary outcome was deep incisional or organ space SSI caused by S aureus. Multivariable logistic regression with generalized estimating equation (GEE) and interrupted time-series (ITS) models were used to compare SSI rates between preintervention and postintervention periods.

Results

Among 6696 cardiac surgical procedures and 16 309 TJAs, 95 S aureus deep incisional or organ space SSIs were detected (25 after cardiac operations and 70 after TJAs). While the GEE model suggested a significant association between the intervention and decreased SSI rates after TJAs (adjusted odds ratio, 0.55; 95% CI, 0.31-0.98), there was not a significant association when an ITS model was used (adjusted incidence rate ratio, 0.88; 95% CI, 0.32-2.39). No significant associations after cardiac operations were found.

Conclusions and Relevance

Although this quality improvement study suggests an association between implementation of an SSI prevention bundle and decreased S aureus deep incisional or organ space SSI rates after TJAs, it was underpowered to see a significant difference when accounting for changes over time.

Prevalence of One-Year Mortality after Implantable Cardioverter Defibrillator Placement: An Opportunity for Palliative Care?

Background: Current guidelines recommend against placement of implantable cardioverter defibrillators in patients with a life expectancy less than one year. These patients may benefit from early palliative care services; however, identifying this population is challenging. Objective: Determine whether a validated prognostic tool, based on patient factors and health care utilization from electronic medical records, accurately predicts one-year mortality at the time of implantable cardioverter defibrillator placement. Design: We used the United States (U.S.) Veterans Administration's "Care Assessment Needs" one-Year Mortality Score to identify patients at high risk of mortality (score ≥95) before their procedure. Data were extracted from the Corporate Data Warehouse. Logistic regression was used to assess the odds of mortality at different score levels. Setting/Subjects: Patients undergoing a new implantable cardioverter defibrillator procedure between October 1, 2015 and September 30, 2017 in the U.S. Veterans Administration. Results: Of 3194 patients with a new implantable cardioverter defibrillator placed, 657 (21.8%) had a score ≥95. The mortality rate among these patients was 151/657 (22.9%) compared with 281/3194 (8.8%) for all patients undergoing a new implantable cardioverter defibrillator procedure. Patients with a score ≥95 had 14.0 (95% confidence interval 8.0-24.4) higher odds of death within one year of the procedure compared with those with a score ≤60. Conclusions: The "Care Assessment Needs" Score is a valid predictor of one-year mortality following implantable cardioverter defibrillator procedures. Integrating its use into the management of Veterans Administration (VA) patients considering implantable cardioverter defibrillators may improve shared decision making and engagement with palliative care.

Efficacy of Diet on Fatigue and Quality of Life in Multiple Sclerosis: A Systematic Review and Network Meta-analysis of Randomized Trials

BACKGROUND AND OBJECTIVE

Emerging evidence suggests a role for diet in multiple sclerosis (MS) care; however, owing to methodological issues and heterogeneity of dietary interventions in preliminary trials, the current state of evidence does not support dietary recommendations for MS. The objective of this study was to assess the efficacy of different dietary approaches on MS-related fatigue and quality of life (QoL) through a systematic review of the literature and network meta-analysis (NMA).

METHODS

Electronic database searches were performed in May 2021. Inclusion criteria were (1) randomized trial with a dietary intervention, (2) adults with definitive MS based on McDonald criteria, (3) patient-reported outcomes for fatigue and/or QoL, and (4) minimum intervention period of 4 weeks. For each outcome, standardized mean differences (SMDs) were calculated and included in random effects NMA to determine the pooled effect of each dietary intervention relative to each of the other dietary interventions. The protocol was registered at PROSPERO (CRD42021262648).

RESULTS

Twelve trials comparing 8 dietary interventions (low-fat, Mediterranean, ketogenic, anti-inflammatory, Paleolithic, fasting, calorie restriction, and control [usual diet]), enrolling 608 participants, were included in the primary analysis. The Paleolithic (SMD -1.27; 95% CI -1.81 to -0.74), low-fat (SMD -0.90; 95% CI -1.39 to -0.42), and Mediterranean (SMD -0.89; 95% CI -1.15 to -0.64) diets showed greater reductions in fatigue compared with control. The Paleolithic (SMD 1.01; 95% CI 0.40-1.63) and Mediterranean (SMD 0.47; 95% CI 0.08-0.86) diets showed greater improvements in physical QoL compared with control. For improving mental QoL, the Paleolithic (SMD 0.81; 95% CI 0.26-1.37) and Mediterranean (SMD 0.36; 95% CI 0.06-0.65) diets were more effective compared with control. However, the NutriGRADE credibility of evidence for all direct comparisons is very low because of most of the included trials having high or moderate risk of bias, small sample sizes, and the limited number of studies included in this NMA.

DISCUSSION

Several dietary interventions may reduce MS-related fatigue and improve physical and mental QoL; however, because of the limitations of this NMA, which are driven by the low quality of the included trials, these findings must be confirmed in high-quality, randomized, controlled trials.

Comparative effectiveness of antibiotic therapy for carbapenem-resistant Enterobacterales (CRE) bloodstream infections in hospitalized US veterans

BACKGROUND

Carbapenem-resistant Enterobacterales bloodstream infections (CRE-BSI) increase mortality three-fold compared with carbapenem-susceptible bloodstream infections. Because these infections are rare, there is a paucity of information on mortality associated with different treatment regimens. This study examines treatment regimens and association with in-hospital, 30 day and 1 year mortality risk for patients with CRE-BSI.

METHODS

This retrospective cohort study identified hospitalized patients within the Veteran Affairs (VA) from 2013 to 2018 with a positive CRE blood culture and started antibiotic treatment within 5 days of culture. Primary outcomes were in-hospital, 30 day and 1 year all-cause mortality. Secondary outcomes were healthcare costs at 30 days and 1 year and Clostridioides difficile infection 6 weeks post culture date. The propensity for receiving each treatment regimen was determined. Multivariable regression assessed the association between treatment and outcomes.

RESULTS

There were 393 hospitalized patients from 2013 to 2018 included in the study. The cohort was male (97%) and elderly (mean age 71.0 years). Carbapenems were the most prescribed antibiotics (47%). In unadjusted analysis, ceftazidime/avibactam was associated with a lower likelihood of 30 day and 1 year mortality. After adjusting, ceftazidime/avibactam had a 30 day mortality OR of 0.42 (95% CI 0.17-1.02). No difference was found in C. difficile incidence at 6 weeks post-infection or total costs at 30 days or 1 year post culture date by any treatments.

CONCLUSIONS

In hospitalized veterans with CRE-BSI, none of the treatments were shown to be associated with all-cause mortality. Ceftazidime/avibactam trended towards protectiveness against 30 day and 1 year all-cause mortality. Use of ceftazidime/avibactam should be encouraged for treatment of CRE-BSI.

Effectiveness and Optimal Duration of Adjunctive Rifampin Treatment in the Management of Staphylococcus Aureus Prosthetic Joint Infections after Debridement, Antibiotics and Implant Retention

Objectives

Rifampin is recommended as adjunctive therapy for patients with a Staphylococcus aureus prosthetic joint infection (PJI) managed with debridement, antibiotics, and implant retention (DAIR) with no solid consensus on the optimal duration of therapy. Our study assessed the effectiveness and optimal duration of rifampin for S. aureus PJI using Veterans Health Administration (VHA) data.

Methods

We conducted a retrospective cohort study of patients with S. aureus PJI managed with DAIR between 2003 and 2019 in VHA hospitals. Patients who died within 14 days after DAIR were excluded. The primary outcome was a time to microbiological recurrence from 15 days up to two years after DAIR. Rifampin use was analyzed as a time-varying exposure, and time-dependent hazard ratios (HRs) for recurrence were calculated according to the duration of rifampin treatment.

Results

Among 4,624 patients, 842 (18.2%) received at least one dose of rifampin. 1785 (38.6%) experienced recurrence within two years. Rifampin treatment was associated with significantly lower HRs for recurrence during the first 90 days of treatment (HR 0.60; 95%CI 0.45-0.79) and between days 91 and 180 (HR 0.16; 95%CI 0.04-0.66) but no statistically significant protective effect was observed with longer than 180 days (HR 0.57; 95%CI 0.18-1.81). The benefit of rifampin was observed for subgroups including knee PJI, MSSA or MRSA infection, and early or late PJI.

Conclusions

This study supports current guidelines which recommend adjunctive rifampin use for up to six months among patients with S. aureus PJI treated with DAIR.

Association of Nonobstructive Chronic Bronchitis With All-Cause Mortality: A Systematic Literature Review and Meta-analysis

BACKGROUND

The effect of nonobstructive chronic bronchitis (CB) on mortality is unclear.

RESEARCH QUESTION

Is nonobstructive CB associated with increased all-cause mortality?

STUDY DESIGN AND METHODS

We conducted a systematic literature review and meta-analysis to assess the association of nonobstructive CB and all-cause mortality. We searched for articles that included both CB and mortality in the title, abstract, or both in PubMed and EMBASE. We excluded studies in which participants demonstrated obstructive spirometry findings and studies in which CB and mortality were not defined. We used the Newcastle-Ottawa Quality Assessment Scale to assess study quality. We pooled adjusted hazard ratios (HRs) using the random effects model and inverse variance weighting. We conducted stratified analysis by the definition of CB and smoking status. We used Cochran's Q and I² to assess for heterogeneity. We assessed publication bias by visual inspection of a funnel plot.

RESULTS

Of 5,014 titles identified, eight fulfilled the inclusion and exclusion criteria. Overall nonobstructive CB was associated with all-cause mortality (HR, 1.37; 95% CI, 1.26-1.50) with no statistically significant heterogeneity (P = .14; I² = 29%). Nonobstructive CB was associated with increased mortality in studies that defined CB as any respiratory symptoms (broad definition; HR, 1.28; 95% CI, 1.10-1.48; I² = 0%) as well as in the rest of the studies (HR, 1.40; 95% CI, 1.26-1.56; I² = 37%). Nonobstructive CB was associated with increased mortality in ever smokers (HR, 1.49; 95% CI, 1.35-1.64; I² = 0%), but was not associated with increased mortality in never smokers (HR, 1.22; 95% CI, 0.90-1.66), and moderate heterogeneity was found (P = .10; I² = 49%). The funnel plot did not indicate evidence of a publication bias because it showed symmetrical distribution of studies.

INTERPRETATION

Nonobstructive CB is associated with increased all-cause mortality, and this association seems to be present only in current and former smokers. Further research should investigate whether this high-risk population may benefit from early therapeutic intervention.

TRIAL REGISTRY

PROSPERO; No.: CRD42021253596; URL: www.crd.york.ac.uk/prospero.

The Effectiveness of Combination Therapy for Treating Methicillin-Susceptible Staphylococcus aureus Bacteremia: A Systematic Literature Review and a Meta-Analysis

Background: This meta-analysis aims to evaluate the effectiveness of combination therapy for treating MSSA bacteremia. Methods: We searched Ovid MEDLINE, EMBASE, Cochrane CENTRAL, and clinicaltrials.gov for studies including adults with MSSA bacteremia. The monotherapy group used a first-line antibiotic active against MSSA and the combination group used a first-line antibiotic plus additional antibiotic/s. The primary outcome was all-cause mortality. Secondary outcomes included persistent bacteremia, duration of bacteremia, relapse, and adverse events. Random-effects models with inverse variance weighting were used to estimate pooled risk ratios (pRR). Heterogeneity was assessed using the I² value and the Cochrane’s Q statistic. Results: A total of 12 studies (6 randomized controlled trials [RCTs]) were included. Combination therapy did not significantly reduce 30-day mortality (pRR 0.92, 95% CI, 0.70–1.20), 90-day mortality (pRR 0.89, 95% CI, 0.74–1.06), or any-time mortality (pRR 0.91, 95% CI, 0.76–1.08). Among patients with deep-seated infections, adjunctive rifampicin may reduce 90-day mortality (3 studies with moderate-high risk of bias; pRR 0.62, 95% CI, 0.42–0.92). For secondary outcomes, combination therapy decreased the risk of relapse (pRR 0.38, 95% CI, 0.22–0.66), but this benefit was not maintained when pooling RCTs (pRR 0.54, 95% CI, 0.12–2.51). Combination therapy was associated with an increased risk of adverse events (pRR 1.74, 95% CI, 1.31–2.31). Conclusions: Combination therapy not only did not decrease mortality in patients with MSSA bacteremia, but also increased the risk of adverse events. Combination therapy may reduce the risk of relapse, but additional high-quality studies are needed.

Impact of infectious diseases consultation on the outcome of patients with enterococcal bacteremia: a systematic literature review and meta-analysis

Background

Enterococcal bacteremia carries significant mortality. While multiple studies have evaluated the impact of infectious disease consultation (IDC) on this condition, these studies were limited by the low numbers of patients enrolled. This systemic literature review and meta-analysis were conducted to determine whether IDC was associated with a mortality benefit among patients with enterococcal bacteremia.

Methods

We performed a systematic literature search using 5 databases for studies evaluating IDC among patients with enterococcal bacteremia. We conducted a meta-analysis to assess whether IDC was associated with reduced mortality. Random-effect models were used to calculated pooled odds ratios (pORs). Heterogeneity was evaluated using I2 estimation and the Cochrane Q statistic test.

Results

The systemic literature review revealed 6496 reports, from which 18 studies were evaluated in the systemic literature review and 16 studies in the meta-analysis. When all studies were pooled, the association between IDC and mortality was not statistically significant with a pOR of 0.81 (95% CI, 0.61-1.08) and there was substantial heterogeneity (I2=58%). When the studies were limited to those reporting multivariate analysis including IDC, there was a significant protective effect of IDC (pOR=0.40; 95% CI, 0.24-0.68) without heterogeneity (I2=0%). Some studies also showed additional benefits to IDC, including appropriate antibiotic therapy, and improved diagnostic use.

Conclusions

IDC was associated with 60% lower odds of mortality when patients were well-matched, potentially through improvement in the care for patients with enterococcal bacteremia. IDC should be considered a part of routine care for patients with enterococcal bacteremia.

Short-term effectiveness of COVID-19 vaccines in immunocompromised patients: A systematic literature review and meta-analysis

OBJECTIVES

We aimed to assess the short-term effectiveness of COVID-19 vaccines among immunocompromised patients to prevent laboratory-confirmed symptomatic COVID-19 infection.

METHODS

Systematic review and meta-analysis. We calculated the pooled diagnostic odds ratio [DOR] (95% CI) for COVID-19 infection between immunocompromised patients and healthy people or those with stable chronic medical conditions. VE was estimated as 100% x (1-DOR). We also investigated the rates of developing anti-SARS-CoV-2 spike protein IgG between the 2 groups.

RESULTS

Twenty studies evaluating COVID-19 vaccine response, and four studies evaluating VE were included in the meta-analysis. The pooled DOR for symptomatic COVID-19 infection in immunocompromised patients was 0.296 (95% CI: 0.108-0.811) with an estimated VE of 70.4% (95% CI: 18.9%- 89.2%). When stratified by diagnosis, IgG antibody levels were much higher in the control group compared to immunocompromised patients with solid organ transplant (pOR 232.3; 95% Cl: 66.98-806.03), malignant diseases (pOR 42.0, 95% Cl: 11.68-151.03), and inflammatory rheumatic diseases (pOR 19.06; 95% Cl: 5.00-72.62).

CONCLUSIONS

We found COVID-19 mRNA vaccines were effective against symptomatic COVID-19 among the immunocompromised patients but had lower VE compared to the controls. Further research is needed to understand the discordance between antibody production and protection against symptomatic COVID-19 infection.

The long-term effectiveness of coronavirus disease 2019 (COVID-19) vaccines: A systematic literature review and meta-analysis

Background

Although multiple studies revealed high vaccine effectiveness of coronavirus disease 2019 (COVID-19) vaccines within 3 months after the completion of vaccines, long-term vaccine effectiveness has not been well established, especially after the δ (delta) variant became prominent. We performed a systematic literature review and meta-analysis of long-term vaccine effectiveness.

Methods

We searched PubMed, CINAHL, EMBASE, Cochrane Central Register of Controlled Trials, Scopus, and Web of Science from December 2019 to November 15, 2021, for studies evaluating the long-term vaccine effectiveness against laboratory-confirmed COVID-19 or COVID-19 hospitalization among individuals who received 2 doses of Pfizer/BioNTech, Moderna, or AstraZeneca vaccines, or 1 dose of the Janssen vaccine. Long-term was defined as >5 months after the last dose. We calculated the pooled diagnostic odds ratio (DOR) with 95% confidence interval for COVID-19 between vaccinated and unvaccinated individuals. Vaccine effectiveness was estimated as 100% × (1 - DOR).

Results

In total, 16 studies including 17,939,172 individuals evaluated long-term vaccine effectiveness and were included in the meta-analysis. The pooled DOR for COVID-19 was 0.158 (95% CI: 0.157-0.160) with an estimated vaccine effectiveness of 84.2% (95% CI, 84.0- 84.3%). Estimated vaccine effectiveness against COVID-19 hospitalization was 88.7% (95% CI, 55.8%-97.1%). Vaccine effectiveness against COVID-19 during the δ variant period was 61.2% (95% CI, 59.0%-63.3%).

Conclusions

COVID-19 vaccines are effective in preventing COVID-19 and COVID-19 hospitalization across a long-term period for the circulating variants during the study period. More observational studies are needed to evaluate the vaccine effectiveness of third dose of a COVID-19 vaccine, the vaccine effectiveness of mixing COVID-19 vaccines, COVID-19 breakthrough infection, and vaccine effectiveness against newly emerging variants.

Promoting de-implementation of inappropriate antimicrobial use in cardiac device procedures by expanding audit and feedback: protocol for hybrid III type effectiveness/implementation quasi-experimental study

BACKGROUND

Despite a strong evidence base and clinical guidelines specifically recommending against prolonged post-procedural antimicrobial use, studies indicate that the practice is common following cardiac device procedures. Formative evaluations conducted by the study team suggest that inappropriate antimicrobial use may be driven by information silos that drive provider belief that antimicrobials are not harmful, in part due to lack of complete feedback about all types of clinical outcomes. De-implementation is recognized as an important area of research that can lead to reductions in unnecessary, wasteful, or harmful practices, such as excess antimicrobial use following cardiac device procedures; however, investigations into strategies that lead to successful de-implementation are limited. The overarching hypothesis to be tested in this trial is that a bundle of implementation strategies that includes audit and feedback about direct patient harms caused by inappropriate prescribing can lead to successful de-implementation of guideline-discordant care.

METHODS

We propose a hybrid type III effectiveness-implementation stepped-wedge intervention trial at three high-volume, high-complexity VA medical centers. The main study intervention (an informatics-based, real-time audit-and-feedback tool) was developed based on learning/unlearning theory and formative evaluations and guided by the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) Framework. Elements of the bundled and multifaceted implementation strategy to promote appropriate prescribing will include audit-and-feedback reports that include information about antibiotic harms, stakeholder engagement, patient and provider education, identification of local champions, and blended facilitation. The primary study outcome is adoption of evidence-based practice (de-implementation of inappropriate antimicrobial use). Clinical outcomes (cardiac device infections, acute kidney injuries and Clostridioides difficile infections) are secondary. Qualitative interviews will assess relevant implementation outcomes (acceptability, adoption, fidelity, feasibility).

DISCUSSION

De-implementation theory suggests that factors that may have a particularly strong influence on de-implementation include strength of the underlying evidence, the complexity of the intervention, and patient and provider anxiety and fear about changing an established practice. This study will assess whether a multifaceted intervention mapped to identified de-implementation barriers leads to measurable improvements in provision of guideline-concordant antimicrobial use. Findings will improve understanding about factors that impact successful or unsuccessful de-implementation of harmful or wasteful healthcare practices.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05020418.

813. Implementing a Nurse-driven Nasal Decolonization Intervention to Prevent Surgical Site Infections within the Veterans Health Administration

Background

Staphylococcus aureus surgical site infection (SSI) is common and devastating clinically. Pre-operative decolonization is associated with reduced incidence, but has been variably adopted due to barriers implementing high-efficacy prevention bundles, including unintentional non-compliance applying intra-nasal mupirocin by patients at home. Three Veterans Affairs (VA) facilities attempted to implement an alternate evidence-based SSI prevention program that included intranasal povidone-iodine used in the pre-operative setting to reduce challenging patient-burden steps and to overcome other mupirocin barriers. Our objective was to identify strategies used for successful implementation of intranasal povidone-iodine.

Methods

We conducted pre- and post-implementation semi-structured interviews and site visits at three VA hospitals. Participants included surgery and clinic staff (e.g., nurses, physicians, care managers), infection control staff, and administrative leadership. Interviews were audio recorded and transcribed. Our interdisciplinary team performed a deductive and inductive consensus-based analysis.

Results

Implementation of this SSI prevention process was successful when nurse champions drove the implementation. Qualitative interviews indicate that nurses used a variety of strategies and messages variant on their audience. Nurse-driven facilitators included: key leadership buy-in and strategic decisions about timing and setting of implementation (i.e., start implementation in units with likely early adopters then when project is working well circle back to the early detractors). The primary implementation barrier identified was lack of a champion. One site stated that in the absence of a champion, a mandate or top-down approach may be needed for implementation at their facility.

Conclusion

Nurse champions facilitated successful SSI prevention process implementation. Nurses used strategies and approaches dependent on their knowledge and understanding of the stakeholders and setting to obtain buy-in. Future implementation of new clinical practices should consider utilizing nurse champions to promote uptake.

Disclosures

Marin L. Schweizer, PhD, 3M (Grant/Research Support)PDI (Grant/Research Support)

235. Outcomes Associated with Extended Oral Antibiotic Prophylaxis After 2-Stage Exchange Surgery to Prevent Recurrent Prosthetic Joint Infection

Background

2-stage exchange (2SE) surgery is often used to treat chronic prosthetic joint infections (PJI). IDSA guidelines do not recommend oral antibiotic suppression after 2SE. However, a recent randomized trial suggested that oral antibiotics for 3 months after arthroplasty reimplantation may prevent recurrent PJI. Objective: To compare rates of treatment failure (i.e., recurrent PJI) and adverse reactions (ARs) among patients who received < 1 month of antibiotics directly after reimplantation to those who received 1-3 months of antibiotics following reimplantation (extended antibiotics).

Methods

This retrospective cohort study included patients with hip, knee, or shoulder PJI who underwent 2SE at 83 VA hospitals between the years 2003-2017. PJI was defined using administrative codes and microbiology data. Patients were followed for 5 years to assess treatment failure (TF) and ARs. TF was defined as recurrent PJI, debridement, or reoperation. ARs included Clostridioides difficile infections (CDI), or antibiotic associated diarrhea (AAD) during or 72 hours after antibiotics. Chi-square tests were used to compare outcomes. Cumulative incidence function curves were created to compare TF rates between those who did and did not receive extended antibiotic treatment, incorporating the competing risks of TF and death.

Results

Of the 433 patients, most (97%) received < 1 month of oral antibiotics and 3% received extended antibiotics. The 15 patients who received extended antibiotics had similar rates of TF and ARs compared with patients who received < 1 month of oral antibiotics (Table). However, there was a trend toward higher rates of CDI (6.7% vs. 3.8%) and AAD (13.3% vs. 9.6%) among those who received extended antibiotics. There was no difference in TF comparing extended antibiotics with < 1 month of antibiotics, accounting for death (Figure).

Table: Treatment Failure and Adverse Reactions Among Those Who Did and Did Not Receive Extended Antibiotics

Conclusion

Few patients received extended oral antibiotics in the study period. There were no statistically significant differences in TF or ARs between the 2 groups. Yet, there was a trend toward higher rates of ARs among the extended antibiotic group. Future prospective studies should assess both the potential benefits and ARs associated with extended antibiotics among patients undergoing 2SE surgery.

Disclosures

Marin L. Schweizer, PhD, 3M (Grant/Research Support)PDI (Grant/Research Support) Bruce Alexander, PharmD, Bruce Alexander Consulting (Independent Contractor) Daniel Suh, MS MPH, General Electric (Shareholder)Merck (Shareholder)Moderna (Shareholder)Smile Direct Club (Shareholder) Aaron J. Tande, MD, UpToDate.com (Other Financial or Material Support, Honoraria for medical writing) Andrew Pugely, MD, MBA, Globus Medical (Research Grant or Support)Medtronic (Consultant)United Healthcare (Consultant)

Using nasal povidone-iodine to prevent bloodstream infections and transmission of Staphylococcus aureus among haemodialysis patients: a stepped-wedge cluster randomised control trial protocol

INTRODUCTION

Approximately 38% of haemodialysis patients carry Staphylococcus aureus in their noses, and carriers have a nearly four-fold increased risk of S. aureus access-related bloodstream infections (BSIs) compared with non-carriers. Our objective is to determine the clinical efficacy and effectiveness of a novel intervention using nasal povidone-iodine (PVI) to prevent BSIs among patients in haemodialysis units. We will survey patients and conduct qualitative interviews with healthcare workers to identify barriers and facilitators to implementing the intervention.

METHODS AND ANALYSIS

We will perform an open-label, stepped-wedge cluster randomised trial to assess the effectiveness of nasal PVI compared with standard care. Sixteen outpatient haemodialysis units will participate in the study. The 3-year trial period will be divided into a 4-month baseline period and eight additional 4-month time blocks. The primary outcome of the study will be S. aureus BSI, defined as a S. aureus positive blood culture collected in the outpatient setting or within one calendar day after a hospital admission. The study team will evaluate characteristics of individual patients and the clusters by exposure status (control or intervention) to assess the balance between groups, and calculate descriptive statistics such as average responses separately for control and intervention survey questions.

ETHICS AND DISSEMINATION

This study has received IRB approval from all study sites. A Data Safety and Monitoring Board will monitor this multicentre clinical trial. We will present our results at international meetings. The study team will publish findings in peer-reviewed journals and make each accepted peer-reviewed manuscript publicly available.

TRIAL REGISTRATION NUMBER

NCT04210505.

Outpatient antibiotic prescribing for common infections via telemedicine versus face-to-face visits: Systematic literature review and meta-analysis

Objective

To evaluate the frequency of antibiotic prescribing for common infections via telemedicine compared to face-to-face visits.

Design

Systematic literature review and meta-analysis.

Methods

We searched PubMed, CINAHL, Embase (Elsevier platform) and Cochrane CENTRAL to identify studies comparing frequency of antibiotic prescribing via telemedicine and face-to-face visits without restrictions by publish dates or language used. We conducted meta-analyses of 5 infections: sinusitis, pharyngitis, otitis media, upper respiratory infection (URI) and urinary tract infection (UTI). Random-effect models were used to obtain pooled odds ratios (ORs). Heterogeneity was evaluated with I2 estimation and the Cochran Q statistic test.

Results

Among 3,106 studies screened, 23 studies (1 randomized control study, 22 observational studies) were included in the systematic literature review. Most of the studies (21 of 23) were conducted in the United States. Studies were substantially heterogenous, but stratified analyses revealed that providers prescribed antibiotics more frequently via telemedicine for otitis media (pooled odds ratio [OR], 1.26; 95% confidence interval [CI], 1.04-1.52; I2 = 31%) and pharyngitis (pooled OR, 1.16; 95% CI, 1.01-1.33; I2 = 0%). We detected no significant difference in the frequencies of antibiotic prescribing for sinusitis (pooled OR, 0.86; 95% CI, 0.70-1.06; I2 = 91%), URI (pooled OR, 1.18; 95% CI, 0.59-2.39; I2 = 100%), or UTI (pooled OR, 2.57; 95% CI, 0.88-7.46; I2 = 91%).

Conclusions

Telemedicine visits for otitis media and pharyngitis were associated with higher rates of antibiotic prescribing. The interpretation of these findings requires caution due to substantial heterogeneity among available studies. Large-scale, well-designed studies with comprehensive assessment of antibiotic prescribing for common outpatient infections comparing telemedicine and face-to-face visits are needed to validate our findings.

Hand Hygiene Compliance at Critical Points of Care

BACKGROUND

Most articles on hand hygiene report either overall compliance or compliance with specific hand hygiene moments. These moments vary in the level of risk to patients if healthcare workers (HCWs) are noncompliant. We assessed how task type affected HCWs' hand hygiene compliance.

METHODS

We linked consecutive tasks individual HCWs performed during the Strategies to Reduce Transmission of Antimicrobial Resistant Bacteria in Intensive Care Units (STAR*ICU) study into care sequences and identified task pairs-2 consecutive tasks and the intervening hand hygiene opportunity. We defined tasks as critical and/or contaminating. We determined the odds of critical and contaminating tasks occurring, and the odds of hand hygiene compliance using logistic regression for transition with a random effect adjusting for isolation precautions, glove use, HCW type, and compliance at prior opportunities.

RESULTS

Healthcare workers were less likely to do hand hygiene before critical tasks than before other tasks (adjusted odds ratio [aOR], 0.97 [95% confidence interval {CI}, .95-.98]) and more likely to do hand hygiene after contaminating tasks than after other tasks (aOR, 1.12 [95% CI, 1.10-1.13]). Nurses were more likely to perform both critical and contaminating tasks, but nurses' hand hygiene compliance was better than physicians' (aOR, 0.94 [95% CI, .91-.97]) and other HCWs' compliance (aOR, 0.87 [95% CI, .87-.94]).

CONCLUSIONS

Healthcare workers were more likely to do hand hygiene after contaminating tasks than before critical tasks, suggesting that habits and a feeling of disgust may influence hand hygiene compliance. This information could be incorporated into interventions to improve hand hygiene practices, particularly before critical tasks and after contaminating tasks.