Healthcare facility-onset, healthcare facility-associated Clostridioides difficile infection in Veterans with spinal cord injury and disorder

Incidence, timing, and risk factors for development of gastrointestinal bleeding in acute traumatic spinal cord injury: A systematic review

CONTEXT

Current guidelines recommend four weeks of stress ulcer prophylaxis following traumatic spinal cord injury.

OBJECTIVES

Assess the current literature on the incidence, timing, and risk factors for gastrointestinal bleeding/clinically important gastrointestinal bleeding in the acute setting following a traumatic spinal cord injury and whether the use of stress ulcer prophylaxis has been shown to reduce the rates of gastrointestinal bleeding.

METHODS

A systematic review was performed in PubMed, Embase, Web of Science, and Cochrane Library following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.

RESULTS

A total of 24 articles met the inclusion/exclusion criteria. The average rate of gastrointestinal bleeding among all studies was 5.5% (95% CI = 5.4-5.6%; n = 26,576). The average rate of clinically important gastrointestinal bleeding was 1.8% (95% CI = 1.79-1.82%; n = 3,857). The mean time since injury to when gastrointestinal bleeding occurred ranged from 5 to 22.5 days. For clinically important gastrointestinal bleeding the average time was 16 days or less. Those with cervical injuries had a higher incidence of clinically important gastrointestinal bleeding compared to those with non-cervical injuries (2.7% vs. 0.7%). No study found any difference in the use of stress ulcer prophylaxis in participants with or without gastrointestinal bleeding.

CONCLUSIONS

The overall incidence of clinically important gastrointestinal bleeding among studies was found to be low. Individuals with non-cervical injury were not found to be at high risk of clinically important gastrointestinal bleeding. There was also insufficient evidence to indicate that use of stress ulcer prophylaxis reduces the rate of gastrointestinal bleeding in those with traumatic spinal cord injury.

A Systematic Literature Review on Risk Factors for and Timing of Clostridioides difficile Infection in the United States

INTRODUCTION

Clostridioides difficile infection (CDI) is a major public health threat. Up to 40% of patients with CDI experience recurrent CDI (rCDI), which is associated with increased morbidity. This study aimed to define an at-risk population by obtaining a detailed understanding of the different factors leading to CDI, rCDI, and CDI-related morbidity and of time to CDI.

METHODS

We conducted a systematic literature review (SLR) of MEDLINE (using PubMed) and EMBASE for relevant articles published between January 1, 2016, and November 11, 2022, covering the US population.

RESULTS

Of the 1324 articles identified, 151 met prespecified inclusion criteria. Advanced patient age was a likely risk factor for primary CDI within a general population, with significant risk estimates identified in nine of 10 studies. Older age was less important in specific populations with comorbidities usually diagnosed at earlier age, such as bowel disease and cancer. In terms of comorbidities, the established factors of infection, kidney disease, liver disease, cardiovascular disease, and bowel disease along with several new factors (including anemia, fluid and electrolyte disorders, and coagulation disorders) were likely risk factors for primary CDI. Data on diabetes, cancer, and obesity were mixed. Other primary CDI risk factors were antibiotics, proton pump inhibitors, female sex, prior hospitalization, and the length of stay in hospital. Similar factors were identified for rCDI, but evidence was limited. Older age was a likely risk factor for mortality. Timing of primary CDI varied depending on the population: 2-3 weeks in patients receiving stem cell transplants, within 3 weeks for patients undergoing surgery, and generally more than 3 weeks following solid organ transplant.

CONCLUSION

This SLR uses recent evidence to define the most important factors associated with CDI, confirming those that are well established and highlighting new ones that could help to identify patient populations at high risk.

Management of Asymptomatic Bacteriuria and Urinary Tract Infections in Patients With Neurogenic Bladder and Factors Associated With Inappropriate Diagnosis and Treatment

OBJECTIVE

Inappropriate diagnosis and treatment of asymptomatic bacteriuria (ASB) and urinary tract infection (UTI) are leading causes of antibiotic overuse but have not been well-studied in patients with risks for complicated UTI such as neurogenic bladder (NB). Our aim was to describe ASB and UTI management in patients with NB and assess factors associated with inappropriate management.

DESIGN

Retrospective cohort study.

SETTING

Four Department of Veteran's Affairs (VA) medical centers.

PARTICIPANTS

Adults with NB due to spinal cord injury/disorder (SCI/D), multiple sclerosis (MS), or Parkinson disease (PD) and encounters with an ASB or UTI diagnosis between 2017 and 2018. Clinical and encounter data were extracted from the VA Corporate Data Warehouse and medical record reviews for a stratified sample of 300 encounters from N=291 patients.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Prevalence of appropriate and inappropriate ASB and UTI diagnosis and treatment was summarized. Multivariable logistic regression models assessed factors associated with inappropriate management.

RESULTS

N=200 UTI and N=100 ASB encounters were included for the 291 unique patients (SCI/D, 39.9%; MS, 36.4%; PD, 23.7%). Most patients were men (83.3%), >65 years (62%), and used indwelling or intermittent catheterization (68.3%). Nearly all ASB encounters had appropriate diagnosis (98%). 70 (35%) UTI encounters had inappropriate diagnosis, including 55 (27.5%) with true ASB, all with inappropriate treatment. Among the remaining 145 UTI encounters, 54 (27%) had inappropriate treatment. Peripheral vascular disease, chronic kidney disease, and cerebrovascular disease were associated with increased odds of inappropriate management; indwelling catheter (aOR 0.35, P=.01) and Physical Medicine & Rehabilitation provider (aOR 0.29, P<.01) were associated with decreased odds.

CONCLUSION

Up to half of UTI encounters for patients with NB had inappropriate management, largely due to inappropriate UTI diagnosis in patients with true ASB. Interventions to improve ASB and UTI management in patients with NB should target complex patients with comorbidities being seen by non-rehabilitation providers.

Frontline perspectives of C. difficile infection prevention practice implementation within veterans affairs health care facilities: A qualitative study

BACKGROUND

In 2012, the veteran's affairs (VA) multidrug-resistant organism (MDRO) Program Office launched a national Clostridioides difficile Infection (CDI) Prevention Initiative to address CDI as the most common cause of healthcare associated infections, mandating use of a VA CDI Bundle of prevention practices in inpatient facilities. We draw upon frontline worker perspectives to explore work system barriers and facilitators to the sustained implementation of the VA CDI Bundle using the systems engineering initiative for patient safety (SEIPS) framework.

METHODS

We interviewed 29 key stakeholders at 4 participating sites between October 2019-July 2021. Participants included infection prevention and control (IPC) leaders, nurses, physicians, and environmental management staff. Interviews were analyzed to identify themes and perceptions of facilitators and barriers to CDI prevention.

RESULTS

IPC leadership was most likely to know of the specific VA CDI Bundle components. Other participants demonstrated general knowledge of CDI prevention practices, with role-based variation in the depth of awareness of specific practices. Facilitators included leadership support, mandated CDI training and prevention practices, and readily available training from multiple sources. Barriers included limits to communication about facility or unit-level CDI rates, ambiguous communications about CDI prevention practice updates and VA mandates, and role-hierarchies that may limit team members' clinical contributions.

DISCUSSION

Recommendations include improving centrally-mandated clarity about and standardization of CDI prevention policies, including testing. Regular IPC training updates for all clinical stakeholders are also recommended.

CONCLUSIONS

A work system analysis using SEIPS identified barriers and facilitators to CDI prevention practices that could be addressed both nationally at the system level and locally at the facility level, specifically in the areas of communication and coordination.

High risk of Clostridium difficile infection among spinal cord injured patients after the use of antibiotics commonly used to treat urinary tract infections

AIM

To characterize the use of common urinary tract infections (UTI)-relevant antibiotics after an SCI and determine the risk of Clostridium difficile infection (CDI) from these antibiotics.

METHODS

We used routinely collected data from Ontario (Canada) to conduct a retrospective, cohort study. We identified people >18 years of age with a traumatic SCI between April 2003 and March 2017. The primary exposure was an outpatient UTI-relevant antibiotic prescription during our observation period, and the primary outcome was evidence of a CDI. An adjusted cox proportional hazards model was used, and antibiotic exposure was modeled as a categorical, time-varying variable based on whether the patient likely had a UTI or not.

RESULTS

We identified 2528 people with SCI; 1642 (65%) were exposed at least once to an antibiotic of interest. The most commonly prescribed UTI-relevant antibiotic was fluoroquinolone (34%). Most patients did not have investigations for a UTI before the use of any of the different antibiotic classes. A small number of patients (5%) used chronic (>3 months) UTI-relevant antibiotics. The overall proportion of patients diagnosed with CDI was 7.4% (9.3/10 000 patient-days). The adjusted hazard ratio for CDI within 30 days was 3.5 (95% confidence interval, 1.9-6.7, p < .01) if they were exposed to a UTI-relevant antibiotic likely associated with a UTI, which was similar to the risk from UTI-relevant antibiotics which may not have been for a UTI.

CONCLUSIONS

The rate of CDI is high in this population and outpatient antibiotics that are commonly used for UTIs are a significant risk factor for CDI.