Getting to Zero: Goal Commitment to Reduce Blood Stream Infections

Changes in Antimicrobial Resistance and Etiology of Blood Culture Isolates: Results of a Decade (2010-2019) of Surveillance in a Northern Region of Colombia

Background

Bloodstream infections (BSI) are important causes of morbidity and mortality worldwide. Antimicrobial surveillance is essential for identifying emerging resistance and generating empirical treatment guides, the purpose of this study is to analyze trends in antimicrobial susceptibility of BSI from 2010 to 2019 in healthcare institutions from Medellin and nearby towns in Colombia.

Methods

A Whonet database was analyzed from the GERMEN antimicrobial surveillance network; frequency and antibiotic susceptibility trends were calculated on more frequent microorganisms using Mann Kendall and Sen’s Slope Estimator Test.

Results

61,299 isolates were included; the three microorganisms more frequent showed a significant increasing trend through time E. coli (Sen’s Slope estimator = 0.7 p = <0.01) S. aureus (Sen’s Slope estimator = 0.60 p = <0.01) and K. pneumonia (Sen’s Slope estimator = 0.30 p = <0.01). E. coli showed a significant increase trend in cefepime and ceftazidime resistance, while K. pneumoniae showed a significant increase in resistance to cefepime, ciprofloxacin, and gentamicin. P. aeruginosa increases its susceptibility to all analyzed antibiotics and S. aureus to oxacillin. No increasing trend was observed for carbapenem resistance.

Conclusion

An upward trends was observed in more frequent microorganisms and resistance to third and fourth-generation cephalosporins for E. coli and K pneumoniae; in contrast, not increasing trends in antibiotic resistance was observed for P. aeruginosa and S. aureus. The essential role of AMR-surveillance programs is to point out and identify these trends, which should improve antibiotic resistance control.

Preventing Central Line Blood Stream Infections in Critical Care Patients

Currently, the Centers for Disease Control reports close to 40,000 central line-associated bloodstream infections (CLABSI) occur in acute care facilities in the United States each year. Most are considered preventable. Evidence-based practices such as the CLABSI bundle and central line maintenance bundles have demonstrated their effectiveness in reducing CLABSI. This article reviews these best practices and provides a framework for consistent implementation.

The Association of Antibiotic Stewardship With Fluoroquinolone Prescribing in Michigan Hospitals: A Multi-hospital Cohort Study

BACKGROUND

Fluoroquinolones increase the risk of Clostridioides difficile infection and antibiotic resistance. Hospitals often use pre-prescription approval or prospective audit and feedback to target fluoroquinolone prescribing. Whether these strategies impact aggregate fluoroquinolone use is unknown.

METHODS

This study is a 48-hospital, retrospective cohort of general-care, medical patients hospitalized with pneumonia or positive urine culture between December 2015-September 2017. Hospitals were surveyed on their use of pre-prescription approval and/or prospective audit and feedback to target fluoroquinolone prescribing during hospitalization (fluoroquinolone stewardship). After controlling for hospital clustering and patient factors, aggregate (inpatient and post-discharge) fluoroquinolone (ciprofloxacin, levofloxacin, moxifloxacin) exposure was compared between hospitals with and without fluoroquinolone stewardship.

RESULTS

There were 11 748 patients (6820 pneumonia; 4928 positive urine culture) included at 48 hospitals. All hospitals responded to the survey: 29.2% (14/48) reported using pre-prescription approval and/or prospective audit and feedback to target fluoroquinolone prescribing. After adjustment, fluoroquinolone stewardship was associated with fewer patients receiving a fluoroquinolone (37.1% vs 48.2%; P = .01) and fewer fluoroquinolone treatment days per 1000 patients (2282 vs 3096 days/1000 patients; P = .01), driven by lower inpatient prescribing. However, most (66.6%) fluoroquinolone treatment days occurred after discharge, and hospitals with fluoroquinolone stewardship had twice as many new fluoroquinolone starts after discharge as hospitals without (15.6% vs 8.4%; P = .003).

CONCLUSIONS

Hospital-based stewardship interventions targeting fluoroquinolone prescribing were associated with less fluoroquinolone prescribing during hospitalization, but not at discharge. To limit aggregate fluoroquinolone exposure, stewardship programs should target both inpatient and discharge prescribing.

Characteristics of healthcare organisations struggling to improve quality: results from a systematic review of qualitative studies

BACKGROUND

Identifying characteristics associated with struggling healthcare organisations may help inform improvement. Thus, we systematically reviewed the literature to: (1) Identify organisational factors associated with struggling healthcare organisations and (2) Summarise these factors into actionable domains.

METHODS

Systematic review of qualitative studies that evaluated organisational characteristics of healthcare organisations that were struggling as defined by below-average patient outcomes (eg, mortality) or quality of care metrics (eg, Patient Safety Indicators). Searches were conducted in MEDLINE (via Ovid), EMBASE, Cochrane Library, CINAHL, and Web of Science from database inception through February 8 2018. Qualitative data were analysed using framework-based synthesis and summarised into key domains. Study quality was evaluated using the Critical Appraisal Skills Program tool.

RESULTS

Thirty studies (33 articles) from multiple countries and settings (eg, acute care, outpatient) with a diverse range of interviewees (eg, nurses, leadership, staff) were included in the final analysis. Five domains characterised struggling healthcare organisations: poor organisational culture (limited ownership, not collaborative, hierarchical, with disconnected leadership), inadequate infrastructure (limited quality improvement, staffing, information technology or resources), lack of a cohesive mission (mission conflicts with other missions, is externally motivated, poorly defined or promotes mediocrity), system shocks (ie, events such as leadership turnover, new electronic health record system or organisational scandals that detract from daily operations), and dysfunctional external relations with other hospitals, stakeholders, or governing bodies.

CONCLUSIONS

Struggling healthcare organisations share characteristics that may affect their ability to provide optimal care. Understanding and identifying these characteristics may provide a first step to helping low performers address organisational challenges to improvement.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42017067367.

Searching for management approaches to reduce HAI transmission (SMART): a study protocol

BACKGROUND

Healthcare-associated infections (HAIs) impact patients' lives through prolonged hospitalization, morbidity, and death, resulting in significant costs to both health systems and society. Central line-associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) are two of the most preventable HAIs. As a result, these HAIs have been the focus of significant efforts to identify evidence-based clinical strategies to reduce infection rates. The Comprehensive Unit-based Safety Program (CUSP) provides a formal model for translating CLABSI-reduction evidence into practice. Yet, a national demonstration project found organizations experienced variable levels of success using CUSP to reduce CLABSIs. In addition, in Fiscal year 2019, Medicare will expand use of CLABSI and CAUTI metrics beyond ICUs to the entire hospital for reimbursement purposes. As a result, hospitals need guidance about how to successfully translate HAI-reduction efforts such as CUSP to non-ICU settings (clinical practice), and how to shape context (management practice)-including culture and management strategies-to proactively support clinical teams.

METHODS

Using a mixed-methods approach to evaluate the contribution of management factors to successful HAI-reduction efforts, our study aims to: (1) Develop valid and reliable measures of structural management practices associated with the recommended CLABSI Management Strategies for use as a survey (HAI Management Practice Guideline Survey) to support HAI-reduction efforts in both medical/surgical units and ICUs; (2) Develop, validate, and then deploy the HAI Management Practice Guideline Survey, first across Ohio hospitals, then nationwide, to determine the positive predictive value of the measurement instrument as it relates to CLABSI- and CAUTI-prevention; and (3) Integrate findings into a Management Practices Toolkit for HAI reduction that includes an organization-specific data dashboard for monitoring progress and an implementation program for toolkit use, and disseminate that Toolkit nationwide.

DISCUSSION

Providing hospitals with the tools they need to successfully measure management structures that support clinical care provides a powerful approach that can be leveraged to reduce the incidence of HAIs experienced by patients. This study is critical to providing the information necessary to successfully "make health care safer" by providing guidance on how contextual factors within a healthcare setting can improve patient safety across hospitals.