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Singh HK, Claeys KC, Advani SD, Ballam YJ, Penney J, Schutte KM, Baliga C, Milstone AM, Hayden MK, Morgan DJ, Diekema DJ. Diagnostic stewardship to improve patient outcomes and healthcare-associated infection (HAI) metrics. Infect Control Hosp Epidemiol 2024; 45:405-411. [PMID: 38204365 PMCID: PMC11007360 DOI: 10.1017/ice.2023.284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 11/22/2023] [Accepted: 11/24/2023] [Indexed: 01/12/2024]
Abstract
Diagnostic stewardship seeks to improve ordering, collection, performance, and reporting of tests. Test results play an important role in reportable HAIs. The inclusion of HAIs in public reporting and pay for performance programs has highlighted the value of diagnostic stewardship as part of infection prevention initiatives. Inappropriate testing should be discouraged, and approaches that seek to alter testing solely to impact a reportable metric should be avoided. HAI definitions should be further adapted to new testing technologies, with focus on actionable and clinically relevant test results that will improve patient care.
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Affiliation(s)
- Harjot K. Singh
- Division of Infectious Diseases, Weill Cornell Medicine, New York City, New York
| | - Kimberly C. Claeys
- Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, Maryland
| | - Sonali D. Advani
- Department of Medicine–Infectious Diseases, Duke University School of Medicine, Durham, North Carolina
| | - Yolanda J. Ballam
- Infection Prevention and Control, Children’s Mercy Kansas City, Missouri
| | - Jessica Penney
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts
| | - Kirsten M. Schutte
- Medical Director, Infectious Disease, eviCore Healthcare, Bluffton, South Carolina
| | - Christopher Baliga
- Section of Infectious Diseases, Department of Medicine, Virginia Mason Hospital and Seattle Medical Center, Seattle, Washington
| | - Aaron M. Milstone
- Division of Pediatric Infectious Diseases, Johns Hopkins Medicine, Baltimore, Maryland
| | - Mary K. Hayden
- Division of Infectious Diseases, Rush University Medical Center, Chicago, Illinois
| | - Daniel J. Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
- Veterans’ Affairs Maryland Healthcare System, Baltimore, Maryland
| | - Daniel J. Diekema
- Division of Infectious Diseases, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
- Division of Infectious Diseases, Department of Medicine, Maine Medical Center, Portland, Maine
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2
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Xiao S, Abade A, Boru W, Kasambara W, Mwaba J, Ongole F, Mmanywa M, Trovão NS, Chilengi R, Kwenda G, Orach CG, Chibwe I, Bwire G, Stine OC, Milstone AM, Lessler J, Azman AS, Luo W, Murt K, Sack DA, Debes AK, Wohl S. New Vibrio cholerae sequences from Eastern and Southern Africa alter our understanding of regional cholera transmission. medRxiv 2024:2024.03.28.24302717. [PMID: 38585829 PMCID: PMC10996759 DOI: 10.1101/2024.03.28.24302717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
Despite ongoing containment and vaccination efforts, cholera remains prevalent in many countries in sub-Saharan Africa. Part of the difficulty in containing cholera comes from our lack of understanding of how it circulates throughout the region. To better characterize regional transmission, we generated and analyzed 118 Vibrio cholerae genomes collected between 2007-2019 from five different countries in Southern and Eastern Africa. We showed that V. cholerae sequencing can be successful from a variety of sample types and filled in spatial and temporal gaps in our understanding of circulating lineages, including providing some of the first sequences from the 2018-2019 outbreaks in Uganda, Kenya, Tanzania, Zambia, and Malawi. Our results present a complex picture of cholera transmission in the region, with multiple lineages found to be co-circulating within several countries. We also find evidence that previously identified sporadic cases may be from larger, undersampled outbreaks, highlighting the need for careful examination of sampling biases and underscoring the need for continued and expanded cholera surveillance across the African continent.
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Affiliation(s)
- Shaoming Xiao
- Division of Pediatric Infectious Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Ahmed Abade
- Ministry of Health, Dar es Salaam, Tanzania
- Field Epidemiology and Laboratory Training Program, Nairobi, Kenya
| | - Waqo Boru
- Field Epidemiology and Laboratory Training Program, Nairobi, Kenya
| | | | - John Mwaba
- Center for Infectious Disease Research, Zambia
- Department of Pathology and Microbiology, University Teaching Hospital, Lusaka, Zambia
| | | | | | | | - Roma Chilengi
- Zambia National Public Health Institute, Lusaka, Zambia
| | | | | | | | | | - O Colin Stine
- University of Maryland School of Medicine, Baltimore, USA
| | - Aaron M Milstone
- Division of Pediatric Infectious Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Justin Lessler
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Epidemiology, Gillings School of Public Health, University of North Carolina, Chapel Hill, NC, USA
- Carolina Population Center, University of North Carolina, Chapel Hill, NC, USA
| | - Andrew S Azman
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, Geneva, Switzerland
- Geneva Centre for Emerging Viral Diseases, Geneva University Hospitals, Geneva, Switzerland
| | - Wensheng Luo
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kelsey Murt
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Biomedical Sciences, School of Health Sciences, University of Zambia, Lusaka, Zambia
| | - David A Sack
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Amanda K Debes
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Shirlee Wohl
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA
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3
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Wade SA, Ali I, Milstone AM, Clever SL, Xiao S, Koontz DW, Hansoti B. Medical education during the COVID-19 pandemic: a reflection on the JHUSOM experience. BMC Med Educ 2024; 24:335. [PMID: 38528473 PMCID: PMC10964593 DOI: 10.1186/s12909-024-05266-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 03/05/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND We sought to understand the relative risk of COVID-19 infection and identify risk factors for infection to identify targets for mitigation among medical students. METHODS An observational cohort study of Johns Hopkins School of Medicine students was conducted from June 2020 to July 2021. Blood samples were collected and tested at three visits to assess for antibodies against SARS-CoV-2. Additionally, a questionnaire was administered at each visit to collect demographic information and assess potential social and behavioral risk factors. RESULTS 264 students enrolled in the study, and 38 participants completed all study requirements by study end. Roughly 6% of the first- and second-year classes had a reported positive COVID-19 test compared to 5% of third- and fourth-year students. By visit 3, 92% of medical students had detectable antibodies against COVID-19 compared to 4% during the study enrollment period. From study enrollment to visit 3, there was a 10-fold increase in the percentage of students reporting attending large social gatherings and dining in restaurants. CONCLUSIONS Overall, few COVID-19 cases were found among medical students, even those on clinical rotations. As the study progressed, students reported engaging in higher-risk social behaviors in conjunction with increasing vaccination rates among students.
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Affiliation(s)
- Sydney A Wade
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Iman Ali
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aaron M Milstone
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sarah L Clever
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Shaoming Xiao
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Danielle Winner Koontz
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bhakti Hansoti
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Department of International Health, Bloomberg School of Public Health, Baltimore, MD, USA.
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4
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Robinson ML, Johnson J, Naik S, Kinikar A, Dohe V, Kagal A, Randive B, Kadam A, Karyakarte R, Mave V, Gupta A, Milstone AM, Manabe YC. The source of Drug-Resistant Bloodstream Infection in the Neonatal Intensive Care Unit, an Ongoing Conversation. Clin Infect Dis 2024:ciae045. [PMID: 38301661 DOI: 10.1093/cid/ciae045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 12/13/2023] [Accepted: 01/26/2024] [Indexed: 02/03/2024] Open
Affiliation(s)
- Matthew L Robinson
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Julia Johnson
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Shilpa Naik
- Department of Obstetrics, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Aarti Kinikar
- Department of Pediatrics, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Vaishali Dohe
- Department of Microbiology, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Anju Kagal
- Department of Microbiology, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Bharat Randive
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - Abhay Kadam
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - Rajesh Karyakarte
- Department of Microbiology, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Vidya Mave
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - Amita Gupta
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Aaron M Milstone
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Yukari C Manabe
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
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Decker S, Xiao S, Dillen C, Schumacher CM, Milstone AM, Frieman M, Debes AK. Association of Nirmatrelvir/Ritonavir Treatment and COVID-19-Neutralizing Antibody Titers in a Longitudinal Health Care Worker Cohort. Open Forum Infect Dis 2024; 11:ofad625. [PMID: 38352152 PMCID: PMC10863641 DOI: 10.1093/ofid/ofad625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Indexed: 02/16/2024] Open
Abstract
Nirmatrelvir/ritonavir (NMV/r) is used for the treatment of coronavirus disease 2019 (COVID-19) infection. However, rebound COVID-19 infections can occur after taking NMV/r. We examined neutralizing antibodies to the severe acute respiratory syndrome coronavirus 2 spike protein before and after infection in people who did and did not take NMV/r to determine if NMV/r impedes the humoral immune response.
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Affiliation(s)
- Slade Decker
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Shaoming Xiao
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Carly Dillen
- Center for Pathogen Research, Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | | | - Aaron M Milstone
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Matthew Frieman
- Center for Pathogen Research, Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Amanda K Debes
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Sick-Samuels AC, Koontz DW, Xie A, Kelly D, Woods-Hill CZ, Aneja A, Xiao S, Colantuoni EA, Marsteller J, Milstone AM. A Survey of PICU Clinician Practices and Perceptions regarding Respiratory Cultures in the Evaluation of Ventilator-Associated Infections in the BrighT STAR Collaborative. Pediatr Crit Care Med 2024; 25:e20-e30. [PMID: 37812030 PMCID: PMC10756695 DOI: 10.1097/pcc.0000000000003379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
OBJECTIVES To characterize respiratory culture practices for mechanically ventilated patients, and to identify drivers of culture use and potential barriers to changing practices across PICUs. DESIGN Cross-sectional survey conducted May 2021-January 2022. SETTING Sixteen academic pediatric hospitals across the United States participating in the BrighT STAR Collaborative. SUBJECTS Pediatric critical care medicine physicians, advanced practice providers, respiratory therapists, and nurses. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We summarized the proportion of positive responses for each question within a hospital and calculated the median proportion and IQR across hospitals. We correlated responses with culture rates and compared responses by role. Sixteen invited institutions participated (100%). Five hundred sixty-eight of 1,301 (44%) e-mailed individuals completed the survey (median hospital response rate 60%). Saline lavage was common, but no PICUs had a standardized approach. There was the highest variability in perceived likelihood (median, IQR) to obtain cultures for isolated fever (49%, 38-61%), isolated laboratory changes (49%, 38-57%), fever and laboratory changes without respiratory symptoms (68%, 54-79%), isolated change in secretion characteristics (67%, 54-78%), and isolated increased secretions (55%, 40-65%). Respiratory cultures were likely to be obtained as a "pan culture" (75%, 70-86%). There was a significant correlation between higher culture rates and likelihood to obtain cultures for isolated fever, persistent fever, isolated hypotension, fever, and laboratory changes without respiratory symptoms, and "pan cultures." Respondents across hospitals would find clinical decision support (CDS) helpful (79%) and thought that CDS would help align ICU and/or consulting teams (82%). Anticipated barriers to change included reluctance to change (70%), opinion of consultants (64%), and concern for missing a diagnosis of ventilator-associated infections (62%). CONCLUSIONS Respiratory culture collection and ordering practices were inconsistent, revealing opportunities for diagnostic stewardship. CDS would be generally well received; however, anticipated conceptual and psychologic barriers to change must be considered.
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Affiliation(s)
- Anna C Sick-Samuels
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
- Department of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, MD
| | - Danielle W Koontz
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Anping Xie
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Armstrong Institute of Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Daniel Kelly
- Division of Medical Critical Care, Department of Pediatrics, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Charlotte Z Woods-Hill
- Division of Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Anushree Aneja
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Shaoming Xiao
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Elizabeth A Colantuoni
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Jill Marsteller
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Armstrong Institute of Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Aaron M Milstone
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
- Department of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, MD
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7
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Aneja A, Johnson J, Prochaska EC, Milstone AM. Microbiome dysbiosis: a modifiable state and target to prevent Staphylococcus aureus infections and other diseases in neonates. J Perinatol 2024; 44:125-130. [PMID: 37904005 PMCID: PMC10842217 DOI: 10.1038/s41372-023-01810-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 10/06/2023] [Accepted: 10/18/2023] [Indexed: 11/01/2023]
Abstract
Bacterial infections present a significant threat to neonates. Increasingly, studies demonstrate associations between human diseases and the microbiota, the communities of microorganisms on or in the body. A "healthy" microbiota with a great diversity and balance of microorganisms can resist harmful pathogens and protect against infections, whereas a microbiota suffering from dysbiosis, can predispose to pathogen colonization and subsequent infection. For decades, strategies such as bacterial interference, decolonization, prebiotics, and probiotics have been tested to reduce Staphylococcus aureus disease and other infections in neonates. More recently, microbiota transplant has emerged as a strategy to broadly correct dysbiosis, promote colonization resistance, and prevent infections. This paper discusses the benefits of a healthy neonate's microbiota, exposures that alter the microbiota, associations of dysbiosis and neonatal disease, strategies to prevent dysbiosis, such as microbiota transplantation, and presents a framework of microbiome manipulation to reduce Staphylococcus aureus (S. aureus) and other infections in neonates.
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Affiliation(s)
- Anushree Aneja
- Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Julia Johnson
- Department of Pediatrics, Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Erica C Prochaska
- Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aaron M Milstone
- Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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8
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Popovich KJ, Aureden K, Ham DC, Harris AD, Hessels AJ, Huang SS, Maragakis LL, Milstone AM, Moody J, Yokoe D, Calfee DP. Reply to Diekema et al. "Are contact precautions "essential" for the prevention of healthcare-associated methicillin-resistant Staphylococcus aureus?". Clin Infect Dis 2023:ciad777. [PMID: 38124511 DOI: 10.1093/cid/ciad777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 12/14/2023] [Indexed: 12/23/2023] Open
Affiliation(s)
| | | | - D Cal Ham
- Centers for Disease Control and Prevention, Atlanta, GA
| | - Anthony D Harris
- Health Care Outcomes Research, University of Maryland School of Medicine, Baltimore, MD
| | - Amanda J Hessels
- Columbia University, School of Nursing, New York, NY. Hackensack Meridian Health, Edison, NJ
| | - Susan S Huang
- Division of Infectious Diseases, University of California Irvine School of Medicine, Irvine, CA
| | - Lisa L Maragakis
- Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Baltimore, MD
| | - Aaron M Milstone
- Division of Pediatric Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Julia Moody
- Infection Prevention, HCA Hospital Corporation of America, Nashville, TN
| | - Deborah Yokoe
- Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, CA
| | - David P Calfee
- Departments of Medicine and Population Health Sciences, Weill Cornell Medicine, New York, NY
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9
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Woods-Hill CZ, Koontz DW, Colantuoni EA, Xiao S, Xie A, Miller MR, Milstone AM. Sustainability of the Bright STAR Diagnostic Stewardship Program to Reduce Blood Culture Rates Among Critically Ill Children. JAMA Pediatr 2023; 177:1234-1237. [PMID: 37695609 PMCID: PMC10495921 DOI: 10.1001/jamapediatrics.2023.3229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 06/09/2023] [Indexed: 09/12/2023]
Abstract
This quality improvement study evaluates whether pediatric intensive care units sustained reduced blood culture rates after participation in the Bright STAR collaborative from 2017 to 2020.
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Affiliation(s)
- Charlotte Z. Woods-Hill
- Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Danielle W. Koontz
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Elizabeth A. Colantuoni
- Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Shaoming Xiao
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Anping Xie
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Marlene R. Miller
- Rainbow Babies and Children’s Hospital, Cleveland, Ohio
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Aaron M. Milstone
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
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10
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Prochaska EC, Caballero TM, Fabre V, Milstone AM. Infection prevention requires attention to patient and caregiver language: Removing language barriers from infection prevention education. Infect Control Hosp Epidemiol 2023; 44:1707-1710. [PMID: 37039600 PMCID: PMC10691433 DOI: 10.1017/ice.2023.58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Affiliation(s)
- Erica C. Prochaska
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Hospital Epidemiology and Infection Control, Johns Hopkins Health System, Baltimore, MD, USA
| | - Tania Maria Caballero
- Department of Pediatrics, Division of General Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Valeria Fabre
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aaron M. Milstone
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Hospital Epidemiology and Infection Control, Johns Hopkins Health System, Baltimore, MD, USA
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11
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Lee JM, Figueroa A, Sachithanandham J, Li M, Connolly CM, Shapiro JR, Chen Y, Jones M, Dhara VG, Towns M, Lee JS, Peralta SR, Milstone AM, Betenbaugh M, Debes AK, Blankson J, Sitaras I, Yoon S, Thompson EA, Bingham CO, Klein SL, Pekosz A, Bailey JR. Three doses of COVID-19 mRNA vaccine induce class-switched antibody responses in inflammatory arthritis patients on immunomodulatory therapies. Front Immunol 2023; 14:1266370. [PMID: 38022602 PMCID: PMC10646683 DOI: 10.3389/fimmu.2023.1266370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/06/2023] [Indexed: 12/01/2023] Open
Abstract
Patients with inflammatory arthritis (IA) are at increased risk of severe COVID-19 due to medication-induced immunosuppression that impairs host defenses. The aim of this study was to assess antibody and B cell responses to COVID-19 mRNA vaccination in IA patients receiving immunomodulatory therapies. Adults with IA were enrolled through the Johns Hopkins Arthritis Center and compared with healthy controls (HC). Paired plasma and peripheral blood mononuclear cell (PBMC) samples were collected prior to and 30 days or 6 months following the first two doses of mRNA vaccines (D2; HC=77 and IA=31 patients), or 30 days following a third dose of mRNA vaccines (D3; HC=11 and IA=96 patients). Neutralizing antibody titers, total binding antibody titers, and B cell responses to vaccine and Omicron variants were analyzed. Anti-Spike (S) IgG and S-specific B cells developed appropriately in most IA patients following D3, with reduced responses to Omicron variants, and negligible effects of medication type or drug withholding. Neutralizing antibody responses were lower compared to healthy controls after both D2 and D3, with a small number of individuals demonstrating persistently undetectable neutralizing antibody levels. Most IA patients respond as well to mRNA COVID-19 vaccines as immunocompetent individuals by the third dose, with no evidence of improved responses following medication withholding. These data suggest that IA-associated immune impairment may not hinder immunity to COVID-19 mRNA vaccines in most individuals.
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Affiliation(s)
- Jenny M. Lee
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States
| | - Alexis Figueroa
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Jaiprasath Sachithanandham
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States
| | - Maggie Li
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States
| | - Caoilfhionn M. Connolly
- Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Janna R. Shapiro
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States
| | - Yiqun Chen
- Department of Chemical and Biomolecular Engineering, Johns Hopkins University, Baltimore, MD, United States
| | - Michelle Jones
- Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Venkata Gayatri Dhara
- Department of Chemical and Biomolecular Engineering, Johns Hopkins University, Baltimore, MD, United States
| | - Marilyn Towns
- Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - John S. Lee
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States
| | - Stephanie R. Peralta
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States
| | - Aaron M. Milstone
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Bloomberg School of Public Health, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Michael Betenbaugh
- Department of Chemical and Biomolecular Engineering, Johns Hopkins University, Baltimore, MD, United States
| | - Amanda K. Debes
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States
| | - Joel Blankson
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Ioannis Sitaras
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States
| | - Steve Yoon
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States
| | - Elizabeth A. Thompson
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Clifton O. Bingham
- Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Sabra L. Klein
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States
| | - Andrew Pekosz
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States
| | - Justin R. Bailey
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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12
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Xie A, Koontz DW, Colantuoni EA, Voskertchian A, Miller MR, Fackler JC, Milstone AM, Woods-Hill CZ. Application of Participatory Ergonomics to the Dissemination of a Quality Improvement Program for Optimizing Blood Culture Use. Jt Comm J Qual Patient Saf 2023; 49:529-538. [PMID: 37429759 PMCID: PMC10688017 DOI: 10.1016/j.jcjq.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 06/02/2023] [Accepted: 06/02/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND Blood cultures are overused in pediatric ICUs (PICUs), which may lead to unnecessary antibiotic use and antibiotic resistance. Using a participatory ergonomics (PE) approach, the authors disseminated a quality improvement (QI) program for optimizing blood culture use in PICUs to a national 14-hospital collaborative. The objective of this study was to evaluate the dissemination process and its impact on blood culture reduction. METHODS The PE approach emphasized three key principles (stakeholder participation, application of human factors and ergonomics knowledge and tools, and cross-site collaboration) with a six-step dissemination process. Data on interactions between sites and the coordinating team and site experiences with the dissemination process were collected using site diaries and semiannual surveys with local QI teams, respectively, and correlated with the site-specific change in blood culture rates. RESULTS Overall, participating sites were able to successfully implement the program and reduced their blood culture rates from 149.4 blood cultures per 1,000 patient-days/month before implementation to 100.5 blood cultures per 1,000 patient-days/month after implementation, corresponding to a 32.7% relative reduction (p < 0.001). Variations in the dissemination process, as well as in local interventions and implementation strategies, were observed across sites. Site-specific changes in blood culture rates were weakly negatively correlated with the number of preintervention interactions with the coordinating team (p = 0.057) but not correlated with their experiences with the six domains of the dissemination process or their interventions. CONCLUSIONS The authors applied a PE approach to disseminate a QI program for optimizing PICU blood culture use to a multisite collaborative. Working with local stakeholders, participating sites tailored their interventions and implementation processes and achieved the goal of reducing blood culture use.
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Affiliation(s)
- Anping Xie
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD, USA
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Danielle W. Koontz
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elizabeth A. Colantuoni
- Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | | | - Marlene R. Miller
- Rainbow Babies and Children’s Hospital, Cleveland, OH, USA
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - James C. Fackler
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aaron M. Milstone
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD, USA
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Charlotte Z. Woods-Hill
- Division of Critical Care Medicine, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
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13
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Wade SA, Ali I, Milstone AM, Clever SL, Xiao S, Koontz DW, Hansoti B. Medical Education during the COVID-19 Pandemic: A Reflection on the JHUSOM Experience. Res Sq 2023:rs.3.rs-3328706. [PMID: 37841861 PMCID: PMC10571620 DOI: 10.21203/rs.3.rs-3328706/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2023]
Abstract
Background We sought to understand the relative risk of COVID-19 infection and identify risk factors for infection to identify targets for mitigation among medical students. Methods An observational cohort study of Johns Hopkins School of Medicine students was conducted from June 2020 to July 2021. Blood samples were collected and tested at three visits to assess for the presence of antibodies against SARS-CoV-2. Additionally, a questionnaire was administered at each visit to collect demographic information and assess potential social and behavioral risk factors. Results 264 students enrolled in the study, and 38 participants completed all study requirements by study end. Roughly 6% of the first- and second-year classes had a reported positive COVID-19 test compared to 5% of third- and fourth-year students. By visit 3, 92% of medical students had detectable antibodies against COVID-19 compared to 4% during the study enrollment period. From study enrollment to visit 3, there was a 10-fold increase in the percentage of students reporting attending large social gatherings and dining in restaurants. Conclusions Overall, few COVID-19 cases were found among medical students, even those on clinical rotations. As the study progressed, students reported engaging in higher-risk social behaviors in conjunction with increasing vaccination rates among students.
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Affiliation(s)
| | - Iman Ali
- Johns Hopkins University School of Medicine
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14
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Kalu IC, Curless MS, Ponnampalavanar S, Milstone AM, Ahmad Kamar A. Strategies to reduce hospital-associated bloodstream infections in a limited resource setting: Preventing Infections in Neonates (PIN) collaborative. Antimicrob Steward Healthc Epidemiol 2023; 3:e144. [PMID: 37780684 PMCID: PMC10540178 DOI: 10.1017/ash.2023.415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 06/22/2023] [Accepted: 06/22/2023] [Indexed: 10/03/2023]
Abstract
Background Hospitalized neonates are at high risk for hospital-associated bloodstream infections (HA-BSI) and require locally contextualized interventions to prevent HA-BSI. Methods The Preventing Infections in Neonates (PIN) collaborative aimed to reach a 50% decrease in neonatal HA-BSI rates for a 27-bed Level IV neonatal intensive care unit (NICU). Using quality improvement (QI) methodologies, a multidisciplinary cross-cultural collaborative implemented phased and bundled interventions from July 2017 to September 2019. Descriptive statistics and statistical process control charts were used to analyze infection rates. Results There were 916 admissions, 19,812 patient-days, and 4264 central line days in the NICU during the project period. Monthly baseline preintervention HA-BSI median rate was 3.95/1000 patient-days and decreased to 1.73/1000 patient-days (56% change) during the bundled interventions. Quarterly HA-BSI rates also decreased from the preintervention median of 4.5/1000 patient-days to 3.3/1000 patient-days during the intervention period (IRR 0.73; 95%CI 0.39, 1.36). Staff were highly compliant with hand hygiene and environmental cleaning. Through project efforts, compliance with bundle elements increased from 25% at baseline to a peak of 97% for central line (CL) insertion checklists and from 13% to a peak of 56% for CL maintenance checklists. Conclusions Unit-based bundled interventions can reduce neonatal HA-BSI in limited resource settings. Future studies can assess similar practices in other units and the impact of the pandemic on interventions to reduce HA-BSIs.
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Affiliation(s)
- Ibukunoluwa C. Kalu
- Department of Pediatrics, Division of Pediatric Infectious Disease, Duke University School of Medicine, Durham, NC, USA
| | - Melanie S. Curless
- Department of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, MD, USA
| | | | - Aaron M. Milstone
- Department of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, MD, USA
- Department of Pediatrics, Division of Pediatric Infectious Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Azanna Ahmad Kamar
- Department of Paediatrics, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
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15
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Affiliation(s)
- Aaron M Milstone
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Pranita D Tamma
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
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16
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Sick-Samuels AC, Booth LD, Milstone AM, Schumacher C, Bergmann J, Stockwell DC. A Novel Comprehensive Algorithm for Evaluation of PICU Patients With New Fever or Instability. Pediatr Crit Care Med 2023; 24:670-680. [PMID: 37125808 PMCID: PMC10392890 DOI: 10.1097/pcc.0000000000003256] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
OBJECTIVES There is variation in microbiology testing among PICU patients with fever offering opportunities to reduce avoidable testing and treatment. Our objective is to describe the development and assess the impact of a novel comprehensive testing algorithm to support judicious testing practices and expanded diagnostic differentials for PICU patients with new fever or instability. DESIGN A mixed-methods quality improvement study. SETTING Single-center academic PICU and pediatric cardiac ICU. SUBJECTS Admitted PICU patients and physicians. INTERVENTIONS A multidisciplinary team developed a clinical decision-support algorithm. MEASUREMENTS AND MAIN RESULTS We evaluated blood, endotracheal, and urine cultures, urinalyses, and broad-spectrum antibiotic use per 1,000 ICU patient-days using statistical process control charts and incident rate ratios (IRRs) and assessed clinical outcomes 24 months pre- and 18 months postimplementation. We surveyed physicians weekly for 12 months postimplementation. Blood cultures declined by 17% (IRR, 0.83; 95% CI, 0.77-0.89), endotracheal cultures by 26% (IRR, 0.74; 95% CI, 0.63-0.86), and urine cultures by 36% (IRR, 0.64; 95% CI, 0.56-0.73). There was an anticipated rise in urinalysis testing by 23% (IRR, 1.23; 95% CI, 1.14-1.33). Despite higher acuity and fewer brief hospitalizations, mortality, hospital, and PICU readmissions were stable, and PICU length of stay declined. Of the 108 physician surveys, 46 replied (43%), and 39 (85%) recently used the algorithm; 0 reported patient safety concerns, two (4%) provided constructive feedback, and 28 (61%) reported the algorithm improved patient care. CONCLUSIONS A comprehensive fever algorithm was associated with reductions in blood, endotracheal, and urine cultures and anticipated increase in urinalyses. We detected no patient harm, and physicians reported improved patient care.
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Affiliation(s)
- Anna C Sick-Samuels
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, MD
- Armstrong Institute of Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Lauren D Booth
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Aaron M Milstone
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, MD
- Armstrong Institute of Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Christina Schumacher
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jules Bergmann
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - David C Stockwell
- Armstrong Institute of Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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17
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Xiao S, Woods-Hill CZ, Koontz D, Thurm C, Richardson T, Milstone AM, Colantuoni E. Comparison of Administrative Database-Derived and Hospital-Derived Data for Monitoring Blood Culture Use in the Pediatric Intensive Care Unit. J Pediatric Infect Dis Soc 2023; 12:436-442. [PMID: 37417679 PMCID: PMC10895403 DOI: 10.1093/jpids/piad048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 07/07/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Optimizing blood culture practices requires monitoring of culture use. Collecting culture data from electronic medical records can be resource intensive. Our objective was to determine whether administrative data could serve as a data source to measure blood culture use in pediatric intensive care units (PICUs). METHODS Using data from a national diagnostic stewardship collaborative to reduce blood culture use in PICUs, we compared the monthly number of blood cultures and patient-days collected from sites (site-derived) and the Pediatric Health Information System (PHIS, administrative-derived), an administrative data warehouse, for 11 participating sites. The collaborative's reduction in blood culture use was compared using administrative-derived and site-derived data. RESULTS Across all sites and months, the median of the monthly relative blood culture rate (ratio of administrative- to site-derived data) was 0.96 (Q1: 0.77, Q3: 1.24). The administrative-derived data produced an estimate of blood culture reduction over time that was attenuated toward the null compared with site-derived data. CONCLUSIONS Administrative data on blood culture use from the PHIS database correlates unpredictably with hospital-derived PICU data. The limitations of administrative billing data should be carefully considered before use for ICU-specific data.
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Affiliation(s)
- Shaoming Xiao
- Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Charlotte Z Woods-Hill
- Division of Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Danielle Koontz
- Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Cary Thurm
- Children's Hospital Association, Lenexa, Kansas, USA
| | | | - Aaron M Milstone
- Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth Colantuoni
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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18
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Affiliation(s)
- Tania M Caballero
- Division of General Pediatrics, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Brandon S A Altillo
- Departments of Pediatrics, Internal Medicine, and Population Health, Dell Medical School, University of Texas, Austin
| | - Aaron M Milstone
- Division of Pediatric Infectious Diseases, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, Maryland
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19
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Robinson ML, Johnson J, Naik S, Patil S, Kulkarni R, Kinikar A, Dohe V, Mudshingkar S, Kagal A, Smith RM, Westercamp M, Randive B, Kadam A, Babiker A, Kulkarni V, Karyakarte R, Mave V, Gupta A, Milstone AM, Manabe YC. Maternal Colonization Versus Nosocomial Transmission as the Source of Drug-Resistant Bloodstream Infection in an Indian Neonatal Intensive Care Unit: A Prospective Cohort Study. Clin Infect Dis 2023; 77:S38-S45. [PMID: 37406039 DOI: 10.1093/cid/ciad282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023] Open
Abstract
BACKGROUND Drug-resistant gram-negative (GN) pathogens are a common cause of neonatal sepsis in low- and middle-income countries. Identifying GN transmission patterns is vital to inform preventive efforts. METHODS We conducted a prospective cohort study, 12 October 2018 to 31 October 2019 to describe the association of maternal and environmental GN colonization with bloodstream infection (BSI) among neonates admitted to a neonatal intensive care unit (NICU) in Western India. We assessed rectal and vaginal colonization in pregnant women presenting for delivery and colonization in neonates and the environment using culture-based methods. We also collected data on BSI for all NICU patients, including neonates born to unenrolled mothers. Organism identification, antibiotic susceptibility testing, and next-generation sequencing (NGS) were performed to compare BSI and related colonization isolates. RESULTS Among 952 enrolled women who delivered, 257 neonates required NICU admission, and 24 (9.3%) developed BSI. Among mothers of neonates with GN BSI (n = 21), 10 (47.7%) had rectal, 5 (23.8%) had vaginal, and 10 (47.7%) had no colonization with resistant GN organisms. No maternal isolates matched the species and resistance pattern of associated neonatal BSI isolates. Thirty GN BSI were observed among neonates born to unenrolled mothers. Among 37 of 51 BSI with available NGS data, 21 (57%) showed a single nucleotide polymorphism distance of ≤5 to another BSI isolate. CONCLUSIONS Prospective assessment of maternal GN colonization did not demonstrate linkage to neonatal BSI. Organism-relatedness among neonates with BSI suggests nosocomial spread, highlighting the importance of NICU infection prevention and control practices to reduce GN BSI.
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Affiliation(s)
- Matthew L Robinson
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Julia Johnson
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Shilpa Naik
- Department of Obstetrics, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Sunil Patil
- Department of Obstetrics, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Rajesh Kulkarni
- Department of Pediatrics, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Aarti Kinikar
- Department of Pediatrics, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Vaishali Dohe
- Department of Microbiology, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Swati Mudshingkar
- Department of Microbiology, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Anju Kagal
- Department of Microbiology, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Rachel M Smith
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Bharat Randive
- Byramjee Jeejeebhoy Government Medical College, Johns Hopkins University Clinical Research Site, Pune, India
| | - Abhay Kadam
- Byramjee Jeejeebhoy Government Medical College, Johns Hopkins University Clinical Research Site, Pune, India
| | - Ahmed Babiker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Vandana Kulkarni
- Byramjee Jeejeebhoy Government Medical College, Johns Hopkins University Clinical Research Site, Pune, India
| | - Rajesh Karyakarte
- Department of Microbiology, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Vidya Mave
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Byramjee Jeejeebhoy Government Medical College, Johns Hopkins University Clinical Research Site, Pune, India
| | - Amita Gupta
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Aaron M Milstone
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yukari C Manabe
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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20
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Popovich KJ, Aureden K, Ham DC, Harris AD, Hessels AJ, Huang SS, Maragakis LL, Milstone AM, Moody J, Yokoe D, Calfee DP. SHEA/IDSA/APIC Practice Recommendation: Strategies to prevent methicillin-resistant Staphylococcus aureus transmission and infection in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol 2023; 44:1039-1067. [PMID: 37381690 PMCID: PMC10369222 DOI: 10.1017/ice.2023.102] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 05/03/2023] [Indexed: 06/29/2023]
Abstract
Previously published guidelines have provided comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute-care hospitals in implementing and prioritizing efforts to prevent methicillin-resistant Staphylococcus aureus (MRSA) transmission and infection. This document updates the "Strategies to Prevent Methicillin-Resistant Staphylococcus aureus Transmission and Infection in Acute Care Hospitals" published in 2014.1 This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.
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Affiliation(s)
- Kyle J. Popovich
- Department of Internal Medicine, RUSH Medical College, Chicago, Illinois
| | - Kathy Aureden
- Infection Prevention, Advocate Aurora Health, Downers Grove, Illinois
| | - D. Cal Ham
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Anthony D. Harris
- Health Care Outcomes Research, University of Maryland School of Medicine, Baltimore, Maryland
| | - Amanda J. Hessels
- Columbia School of Nursing, New York, New York
- Hackensack Meridian Health, Edison, New Jersey
| | - Susan S. Huang
- Division of Infectious Diseases, University of California Irvine School of Medicine, Irvine, California
| | - Lisa L. Maragakis
- Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Aaron M. Milstone
- Division of Pediatric Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Julia Moody
- Infection Prevention, HCA Healthcare, Nashville, Tennessee
| | - Deborah Yokoe
- Department of Medicine, University of California San Francisco School of Medicine, San Francisco, California
- Transplant Infectious Diseases, UCSF Medical Center, San Francisco, California
| | - David P. Calfee
- Department of Medicine, Weill Cornell Medicine, New York, New York
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York
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21
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Martínez DA, Cai J, Lin G, Goodman KE, Paul R, Lessler J, Levin SR, Toerper M, Simner PJ, Milstone AM, Klein EY. Modelling interventions and contact networks to reduce the spread of carbapenem-resistant organisms between individuals in the ICU. J Hosp Infect 2023; 136:1-7. [PMID: 36907332 PMCID: PMC10315994 DOI: 10.1016/j.jhin.2023.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 01/25/2023] [Accepted: 02/03/2023] [Indexed: 03/13/2023]
Abstract
BACKGROUND Contact precautions are widely used to prevent the transmission of carbapenem-resistant organisms (CROs) in hospital wards. However, evidence for their effectiveness in natural hospital environments is limited. OBJECTIVE To determine which contact precautions, healthcare worker (HCW)-patient interactions, and patient and ward characteristics are associated with greater risk of CRO infection or colonization. DESIGN, SETTING AND PARTICIPANTS CRO clinical and surveillance cultures from two high-acuity wards were assessed through probabilistic modelling to characterize a susceptible patient's risk of CRO infection or colonization during a ward stay. User- and time-stamped electronic health records were used to build HCW-mediated contact networks between patients. Probabilistic models were adjusted for patient (e.g. antibiotic administration) and ward (e.g. hand hygiene compliance, environmental cleaning) characteristics. The effects of risk factors were assessed by adjusted odds ratio (aOR) and 95% Bayesian credible intervals (CrI). EXPOSURES The degree of interaction with CRO-positive patients, stratified by whether CRO-positive patients were on contact precautions. MAIN OUTCOMES AND MEASURES The prevalence of CROs and number of new carriers (i.e. incident CRO aquisition). RESULTS Among 2193 ward visits, 126 (5.8%) patients became colonized or infected with CROs. Susceptible patients had 4.8 daily interactions with CRO-positive individuals on contact precautions (vs 1.9 interactions with those not on contact precautions). The use of contact precautions for CRO-positive patients was associated with a reduced rate (7.4 vs 93.5 per 1000 patient-days at risk) and odds (aOR 0.03, 95% CrI 0.01-0.17) of CRO acquisition among susceptible patients, resulting in an estimated absolute risk reduction of 9.0% (95% CrI 7.6-9.2%). Also, carbapenem administration to susceptible patients was associated with increased odds of CRO acquisition (aOR 2.38, 95% CrI 1.70-3.29). CONCLUSIONS AND RELEVANCE In this population-based cohort study, the use of contact precautions for patients colonized or infected with CROs was associated with lower risk of CRO acquisition among susceptible patients, even after adjusting for antibiotic exposure. Further studies that include organism genotyping are needed to confirm these findings.
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Affiliation(s)
- D A Martínez
- School of Industrial Engineering, Pontificia Universidad Católica de Valparaíso, Valparaíso, Chile; Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA; Department of Medicine, Johns Hopkins University, Baltimore, MD, USA.
| | - J Cai
- Department of Applied Mathematics and Statistics, Johns Hopkins University, Baltimore, MD, USA
| | - G Lin
- Center for Disease Dynamics, Economics and Policy, Washington, DC, USA
| | - K E Goodman
- Department of Epidemiology and Public Health, University of Maryland, Baltimore, MD, USA
| | - R Paul
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC, USA
| | - J Lessler
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA; Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - S R Levin
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - M Toerper
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - P J Simner
- Division of Medical Microbiology, Department of Pathology, Johns Hopkins University, Baltimore, MD, USA
| | - A M Milstone
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA; Department of Pediatrics, Johns Hopkins University, Baltimore, MD, USA
| | - E Y Klein
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA; Center for Disease Dynamics, Economics and Policy, Washington, DC, USA; Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
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22
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Saiman L, Coffin SE, Kociolek LK, Zerr DM, Milstone AM, Aldrich ML, Vargas CY, Zapata G, Zalot MA, Reyna ME, Adler A, Voskertchian A, Egbert ER, Alba L, Gollerkeri S, Ruggieri M, Finelli L, Choi Y. Healthcare-associated Respiratory Syncytial Virus in Children's Hospitals. J Pediatric Infect Dis Soc 2023:7152989. [PMID: 37144945 DOI: 10.1093/jpids/piad030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Indexed: 05/06/2023]
Abstract
BACKGROUND Outbreaks of healthcare-associated respiratory syncytial virus (HA-RSV) infections in children are well described, but less is known about sporadic HA-RSV infections. We assessed the epidemiology and clinical outcomes associated with sporadic HA-RSV infections. METHODS We retrospectively identified hospitalized children <18 years old with HA-RSV infections in six children's hospitals in the United States during the respiratory viral seasons October-April in 2016-2017, 2017-2018, and 2018-2019 and prospectively from October 2020 through November 2021. We evaluated outcomes temporally associated with HA-RSV infections including escalation of respiratory support, transfer to the pediatric intensive care unit (PICU), and in-hospital mortality. We assessed demographic characteristics and comorbid conditions associated with escalation of respiratory support. RESULTS We identified 122 children (median age 16.0 months [IQR 6, 60 months]) with HA-RSV. The median onset of HA-RSV infections was hospital day 14 (IQR 7, 34 days). Overall, 78 (63.9%) children had two or more comorbid conditions; cardiovascular, gastrointestinal, neurologic/neuromuscular, respiratory, and premature/ neonatal comorbidities were most common. Fifty-five (45.1%) children required escalation of respiratory support and 18 (14.8%) were transferred to the PICU. Five (4.1%) died during hospitalization. In the multivariable analysis, respiratory comorbidities (aOR: 3.36 [CI95 1.41, 8.01]) were associated with increased odds of escalation of respiratory support. CONCLUSIONS HA-RSV infections cause preventable morbidity and increase healthcare resource utilization. Further study of effective mitigation strategies for HA-respiratory viral infections should be prioritized; this priority is further supported by the impact of the COVID-19 pandemic on seasonal viral infections.
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Affiliation(s)
- Lisa Saiman
- NewYork-Presbyterian Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY
| | - Susan E Coffin
- Children's Hospital of Philadelphia, Philadelphia, PA, Perelman School of Medicine at UPenn, Philadelphia, PA
| | - Larry K Kociolek
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | | | | | | | - Celibell Y Vargas
- NewYork-Presbyterian Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY
| | - Giovanny Zapata
- Mailman School of Public Health, Columbia University Irving Medical Center, New York, NY
| | - Morgan A Zalot
- Children's Hospital of Philadelphia, Philadelphia, PA, Perelman School of Medicine at UPenn, Philadelphia, PA
| | - Megan E Reyna
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | | | | | - Emily R Egbert
- Johns Hopkins University School of Medicine, Baltimore, MD
| | - Luis Alba
- NewYork-Presbyterian Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY
| | - Sonia Gollerkeri
- NewYork-Presbyterian Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY
| | - Madelyn Ruggieri
- Center for Observational and Real-World Evidence, Merck & Co., Inc., Rahway, NJ
| | - Lyn Finelli
- Center for Observational and Real-World Evidence, Merck & Co., Inc., Rahway, NJ
| | - Yoonyoung Choi
- Center for Observational and Real-World Evidence, Merck & Co., Inc., Rahway, NJ
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23
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Smith L, Morris CP, Jibowu MH, Fallon S, Ray SC, Cosgrove SE, Curless MS, Fabre V, Karaba SM, Maragakis LL, Milstone AM, Sick-Samuels AC, Trexler P, Mostafa HH, Rock C. Severe acute respiratory coronavirus virus 2 (SARS-CoV-2) exposure investigations using genomic sequencing among healthcare workers and patients in a large academic center. Infect Control Hosp Epidemiol 2023; 44:798-801. [PMID: 35232508 PMCID: PMC8943229 DOI: 10.1017/ice.2022.37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 01/28/2022] [Accepted: 01/30/2022] [Indexed: 02/04/2023]
Abstract
Severe acute respiratory coronavirus virus 2 (SARS-CoV-2) transmissions among healthcare workers and hospitalized patients are challenging to confirm. Investigation of infected persons often reveals multiple potential risk factors for viral acquisition. We combined exposure investigation with genomic analysis confirming 2 hospital-based clusters. Prolonged close contact with unmasked, unrecognized infectious, individuals was a common risk.
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Affiliation(s)
- Leigh Smith
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, Maryland
| | - C. Paul Morris
- Division of Medical Microbiology, Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland
- National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, Maryland
| | - Morgan H. Jibowu
- Department of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, Maryland
| | - Susan Fallon
- Department of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, Maryland
| | - Stuart C. Ray
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sara E. Cosgrove
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, Maryland
| | - Melanie S. Curless
- Department of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, Maryland
| | - Valeria Fabre
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, Maryland
| | - Sara M. Karaba
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lisa L Maragakis
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, Maryland
| | - Aaron M Milstone
- Department of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, Maryland
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Anna C. Sick-Samuels
- Department of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, Maryland
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Polly Trexler
- Department of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, Maryland
| | - Heba H. Mostafa
- Division of Medical Microbiology, Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Clare Rock
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, Maryland
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24
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Woods-Hill CZ, Nelson MN, Eriksen W, Rendle KA, Beidas RS, Bonafide CP, Brajcich MR, Milstone AM, Shea JA. Determinants of Blood Culture Use in Critically Ill Children: A Multicenter Qualitative Study. Pediatr Qual Saf 2023; 8:e647. [PMID: 37051407 PMCID: PMC10085482 DOI: 10.1097/pq9.0000000000000647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 03/11/2023] [Indexed: 04/14/2023] Open
Abstract
Blood cultures are fundamental in diagnosing and treating sepsis in the pediatric intensive care unit (PICU), but practices vary widely. Overuse can lead to false positive results and unnecessary antibiotics. Specific factors underlying decisions about blood culture use and overuse are unknown. Therefore, we aimed to identify perceived determinants of blood culture use in the PICU. Methods We conducted semistructured interviews of clinicians (M.D., D.O., R.N., N.P., P.A.) from 6 PICUs who had participated in a quality improvement collaborative about blood culture practices. We developed interview questions by combining elements of the Consolidated Framework for Implementation Research and behavioral economics. We conducted telephone interviews, open-coded the transcripts, and used modified content analysis to determine key themes and mapped themes to elements of Consolidated Framework for Implementation Research and behavioral economics. Results We reached thematic saturation in 24 interviews. Seven core themes emerged across 3 Consolidated Framework for Implementation Research domains: individual characteristics [personal belief in the importance of blood cultures, the perception that blood cultures are a low-risk test]; inner setting [adherence to site-specific usual practices, site-specific overall approach to PICU care (collaborative versus hierarchical), influence of non-PICU clinicians on blood culture decisions]; and outer setting [patient-specific risk factors, sepsis guidelines]. In addition, outcome bias, default bias, and loss aversion emerged as salient behavioral economics concepts. Conclusions Determinants of blood culture use include individual clinician characteristics, inner setting, and outer setting, as well as default bias, outcome bias, and loss aversion. These determinants will now inform the development of candidate strategies to optimize culture practices.
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Affiliation(s)
- Charlotte Z. Woods-Hill
- From the Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia Pa
| | - Maria N. Nelson
- University of Pennsylvania Mixed Methods Research Laboratory
| | | | | | | | - Christopher P. Bonafide
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Michelle R. Brajcich
- From the Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa
| | - Aaron M. Milstone
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Judy A. Shea
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
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25
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Egbert ER, Xiao S, Prochaska E, Ali SO, Colantuoni E, Gadala A, Koontz D, Zhong D, Schumacher CM, Sick-Samuels AC, Debes AK, Milstone AM. Association of healthcare worker behaviors with coronavirus disease 2019 (COVID-19) risk during four pandemic periods and characteristics associated with high-risk behaviors. Antimicrob Steward Healthc Epidemiol 2023; 3:e16. [PMID: 36714294 PMCID: PMC9879855 DOI: 10.1017/ash.2022.371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 12/02/2022] [Accepted: 12/02/2022] [Indexed: 01/18/2023]
Abstract
In a large healthcare worker cohort, we quantified the association between behaviors and risk of coronavirus disease 2019 (COVID-19) during different pandemic phases, adjusting for prior infection and vaccination. Individual characteristics, including personal concerns, were associated with these behaviors. Public health messaging should target high-risk populations and behaviors as the pandemic evolves.
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Affiliation(s)
- Emily R. Egbert
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Shaoming Xiao
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Erica Prochaska
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - S. Omar Ali
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Elizabeth Colantuoni
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Avi Gadala
- Johns Hopkins Health System, Baltimore, Maryland
| | - Danielle Koontz
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Diana Zhong
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christina M. Schumacher
- Division of General Pediatrics, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Anna C. Sick-Samuels
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Amanda K. Debes
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Aaron M. Milstone
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
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26
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Freeman MC, Lazzara A, Lennon T, McAteer J, Pease M, Sefcik R, Radovic-Stakic A, Milstone AM, Nowalk A, Trent M. Gonococcal Infection and Ventriculoperitoneal Shunts. Sex Transm Dis 2022; 49:838-840. [PMID: 35797550 PMCID: PMC9669122 DOI: 10.1097/olq.0000000000001671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Neisseria gonorrhoea e and Chlamydia trachomatis are pathogens commonly isolated in pelvic inflammatory disease. Neisseria gonorrhoea e may uncommonly spread outside the urogenital tract to cause complications. We present 2 cases of adolescents with ventriculoperitoneal shunt infection due to N. gonorrhoea e, requiring shunt externalization.
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Affiliation(s)
| | - Alexandra Lazzara
- Department of Pediatrics, Johns Hopkins University School of Medicine
| | - Tyler Lennon
- Department of Pediatrics, Johns Hopkins University School of Medicine
| | - John McAteer
- Department of Pediatrics, Johns Hopkins University School of Medicine
| | - Matthew Pease
- Department of Neurosurgery, University of Pittsburgh School of Medicine
| | - Roberta Sefcik
- Department of Neurosurgery, University of Pittsburgh School of Medicine
| | | | - Aaron M. Milstone
- Department of Pediatrics, Johns Hopkins University School of Medicine
| | - Andrew Nowalk
- Department of Pediatrics, University of Pittsburgh School of Medicine
| | - Maria Trent
- Department of Pediatrics, Johns Hopkins University School of Medicine
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27
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Woods-Hill CZ, Colantuoni EA, Milstone AM. The Implementation of Diagnostic Stewardship for Blood Cultures in Critically Ill Children-Reply. JAMA Pediatr 2022; 176:1151-1152. [PMID: 36066880 PMCID: PMC10659024 DOI: 10.1001/jamapediatrics.2022.3166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Charlotte Z Woods-Hill
- Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Elizabeth A Colantuoni
- Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Aaron M Milstone
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
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28
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Debes AK, Xiao S, Egbert ER, Caturegli P, Gadala A, Colantuoni E, Sitaras I, Pekosz A, Milstone AM. Neutralizing SARS-CoV-2 Spike Antibodies against Omicron in Paired Samples after Two or Three Doses of mRNA Vaccine. Microbiol Spectr 2022; 10:e0204622. [PMID: 36190405 PMCID: PMC9603442 DOI: 10.1128/spectrum.02046-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 09/19/2022] [Indexed: 02/01/2023] Open
Abstract
SARS-CoV-2 antibody levels wane following two-doses of mRNA vaccination. An mRNA booster dose provides increased protection against hospitalization and death. We demonstrated that a booster dose provides a significant increase in the neutralization of the Beta, Delta and Omicron variants in addition to an increased neutralization of the vaccine strain. The total spike IgG measurements, obtained by using commercial kits that target the spike protein from the vaccine strain, may not reflect serum neutralization against variants of concern. IMPORTANCE This study found little to no neutralizing capability following a 2-dose mRNA vaccine series against the omicron variant, and neutralizing capacity to any variant strain tested was lost by 8-months post 2-dose series. However, the mRNA booster dose eliminated the immune escape observed by the Omicron variant, following the 2-dose series. Even more, the neutralizing titers were significantly higher for all variants post-boost, compared to the titers from the post-two-dose series. Our data are unique, using paired samples that eliminate potential confounders that may impact vaccine response. Notably, as seen after the primary two-dose vaccine series, total antibody levels did not correlate perfectly with variant neutralization activity, suggesting that simply testing titers as a measure of protection may not be a long-term solution. Therefore, it is important to reassess the utility of SARS-CoV-2 antibody testing, as current vaccine strain-based testing may not reliably detect reactive antibodies to Omicron or other variants of concern.
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Affiliation(s)
- Amanda K. Debes
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Shaoming Xiao
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Emily R. Egbert
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | | | - Elizabeth Colantuoni
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ioannis Sitaras
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Andrew Pekosz
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Aaron M. Milstone
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Johns Hopkins Health System, Baltimore, Maryland, USA
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29
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Schrank GM, Sick-Samuels A, Bleasdale SC, Jacob JT, Dantes R, Gokhale RH, Mayer J, Mehrotra P, Mehta SA, Mena Lora AJ, Ray SM, Rhee C, Salinas JL, Seo SK, Shane AL, Nadimpalli G, Milstone AM, Robinson G, Brown CH, Harris AD, Leekha S. Development and evaluation of a structured guide to assess the preventability of hospital-onset bacteremia and fungemia. Infect Control Hosp Epidemiol 2022; 43:1326-1332. [PMID: 35086601 PMCID: PMC9472698 DOI: 10.1017/ice.2021.528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To assess preventability of hospital-onset bacteremia and fungemia (HOB), we developed and evaluated a structured rating guide accounting for intrinsic patient and extrinsic healthcare-related risks. DESIGN HOB preventability rating guide was compared against a reference standard expert panel. PARTICIPANTS A 10-member panel of clinical experts was assembled as the standard of preventability assessment, and 2 physician reviewers applied the rating guide for comparison. METHODS The expert panel independently rated 82 hypothetical HOB scenarios using a 6-point Likert scale collapsed into 3 categories: preventable, uncertain, or not preventable. Consensus was defined as concurrence on the same category among ≥70% experts. Scenarios without consensus were deliberated and followed by a second round of rating.Two reviewers independently applied the rating guide to adjudicate the same 82 scenarios in 2 rounds, with interim revisions. Interrater reliability was evaluated using the κ (kappa) statistic. RESULTS Expert panel consensus criteria were met for 52 scenarios (63%) after 2 rounds.After 2 rounds, guide-based rating matched expert panel consensus in 40 of 52 (77%) and 39 of 52 (75%) cases for reviewers 1 and 2, respectively. Agreement rates between the 2 reviewers were 84% overall (κ, 0.76; 95% confidence interval [CI], 0.64-0.88]) and 87% (κ, 0.79; 95% CI, 0.65-0.94) for the 52 scenarios with expert consensus. CONCLUSIONS Preventability ratings of HOB scenarios by 2 reviewers using a rating guide matched expert consensus in most cases with moderately high interreviewer reliability. Although diversity of expert opinions and uncertainty of preventability merit further exploration, this is a step toward standardized assessment of HOB preventability.
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Affiliation(s)
- Gregory M Schrank
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Anna Sick-Samuels
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Susan C Bleasdale
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Jesse T Jacob
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Raymund Dantes
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Runa H Gokhale
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jeanmarie Mayer
- Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Preeti Mehrotra
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Sapna A Mehta
- Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | - Alfredo J Mena Lora
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Susan M Ray
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Chanu Rhee
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | | | - Susan K Seo
- Department of Medicine, Joan and Sanford Weil Cornell Medical College, New York, New York
| | - Andi L Shane
- Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Gita Nadimpalli
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
| | - Aaron M Milstone
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Gwen Robinson
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
| | - Clayton H Brown
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
| | - Anthony D Harris
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
| | - Surbhi Leekha
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
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30
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Shapiro JR, Sitaras I, Park HS, Aytenfisu TY, Caputo C, Li M, Lee J, Johnston TS, Li H, Wouters C, Hauk P, Jacobsen H, Li Y, Abrams E, Yoon S, Kocot AJ, Yang T, Huang Y, Cramer SM, Betenbaugh MJ, Debes AK, Morgan R, Milstone AM, Karaba AH, Pekosz A, Leng SX, Klein SL. Association of Frailty, Age, and Biological Sex With Severe Acute Respiratory Syndrome Coronavirus 2 Messenger RNA Vaccine-Induced Immunity in Older Adults. Clin Infect Dis 2022; 75:S61-S71. [PMID: 35607747 PMCID: PMC9376280 DOI: 10.1093/cid/ciac397] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Male sex and old age are risk factors for severe coronavirus disease 2019, but the intersection of sex and aging on antibody responses to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines has not been characterized. METHODS Plasma samples were collected from older adults (aged 75-98 years) before and after 3 doses of SARS-CoV-2 mRNA vaccination, and from younger adults (aged 18-74 years) post-dose 2, for comparison. Antibody binding to SARS-CoV-2 antigens (spike protein [S], S receptor-binding domain, and nucleocapsid), functional activity against S, and live-virus neutralization were measured against the vaccine virus and the Alpha, Delta, and Omicron variants of concern (VOCs). RESULTS Vaccination induced greater antibody titers in older females than in older males, with both age and frailty associated with reduced antibody responses in males but not females. Responses declined significantly in the 6 months after the second dose. The third dose restored functional antibody responses and eliminated disparities caused by sex, age, and frailty in older adults. Responses to the VOCs, particularly the Omicron variant, were significantly reduced relative to the vaccine virus, with older males having lower titers to the VOCs than older females. Older adults had lower responses to the vaccine and VOC viruses than younger adults, with greater disparities in males than in females. CONCLUSIONS Older and frail males may be more vulnerable to breakthrough infections owing to low antibody responses before receipt of a third vaccine dose. Promoting third dose coverage in older adults, especially males, is crucial to protecting this vulnerable population.
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Affiliation(s)
- Janna R Shapiro
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ioannis Sitaras
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Han Sol Park
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Tihitina Y Aytenfisu
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christopher Caputo
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Maggie Li
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - John Lee
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Trevor S Johnston
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Huifen Li
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Camille Wouters
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Pricila Hauk
- Department of Chemical and Biomolecular Engineering, Johns Hopkins Whiting School of Engineering, Baltimore, Maryland, USA
| | - Henning Jacobsen
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Yukang Li
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Engle Abrams
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Steve Yoon
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Andrew J Kocot
- Department of Chemical and Biological Engineering, Rensselaer Polytechnic Institute, Troy, New York, USA
| | - Tianrui Yang
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yushu Huang
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Steven M Cramer
- Department of Chemical and Biological Engineering, Rensselaer Polytechnic Institute, Troy, New York, USA
| | - Michael J Betenbaugh
- Department of Chemical and Biomolecular Engineering, Johns Hopkins Whiting School of Engineering, Baltimore, Maryland, USA
| | - Amanda K Debes
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Rosemary Morgan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Aaron M Milstone
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Andrew H Karaba
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Andrew Pekosz
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sean X Leng
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Johns Hopkins Center on Aging and Immune Remodeling, Baltimore, Maryland, USA
| | - Sabra L Klein
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Woods-Hill CZ, Colantuoni EA, Koontz DW, Voskertchian A, Xie A, Thurm C, Miller MR, Fackler JC, Milstone AM. Association of Diagnostic Stewardship for Blood Cultures in Critically Ill Children With Culture Rates, Antibiotic Use, and Patient Outcomes: Results of the Bright STAR Collaborative. JAMA Pediatr 2022; 176:690-698. [PMID: 35499841 PMCID: PMC9062771 DOI: 10.1001/jamapediatrics.2022.1024] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 01/15/2022] [Indexed: 12/15/2022]
Abstract
Importance Blood culture overuse in the pediatric intensive care unit (PICU) can lead to unnecessary antibiotic use and contribute to antibiotic resistance. Optimizing blood culture practices through diagnostic stewardship may reduce unnecessary blood cultures and antibiotics. Objective To evaluate the association of a 14-site multidisciplinary PICU blood culture collaborative with culture rates, antibiotic use, and patient outcomes. Design, Setting, and Participants This prospective quality improvement (QI) collaborative involved 14 PICUs across the United States from 2017 to 2020 for the Bright STAR (Testing Stewardship for Antibiotic Reduction) collaborative. Data were collected from each participating PICU and from the Children's Hospital Association Pediatric Health Information System for prespecified primary and secondary outcomes. Exposures A local QI program focusing on blood culture practices in the PICU (facilitated by a larger QI collaborative). Main Outcomes and Measures The primary outcome was blood culture rates (per 1000 patient-days/mo). Secondary outcomes included broad-spectrum antibiotic use (total days of therapy and new initiations of broad-spectrum antibiotics ≥3 days after PICU admission) and PICU rates of central line-associated bloodstream infection (CLABSI), Clostridioides difficile infection, mortality, readmission, length of stay, sepsis, and severe sepsis/septic shock. Results Across the 14 PICUs, the blood culture rate was 149.4 per 1000 patient-days/mo preimplementation and 100.5 per 1000 patient-days/mo postimplementation, for a 33% relative reduction (95% CI, 26%-39%). Comparing the periods before and after implementation, the rate of broad-spectrum antibiotic use decreased from 506 days to 440 days per 1000 patient-days/mo, respectively, a 13% relative reduction (95% CI, 7%-19%). The broad-spectrum antibiotic initiation rate decreased from 58.1 to 53.6 initiations/1000 patient-days/mo, an 8% relative reduction (95% CI, 4%-11%). Rates of CLABSI decreased from 1.8 to 1.1 per 1000 central venous line days/mo, a 36% relative reduction (95% CI, 20%-49%). Mortality, length of stay, readmission, sepsis, and severe sepsis/septic shock were similar before and after implementation. Conclusions and Relevance Multidisciplinary diagnostic stewardship interventions can reduce blood culture and antibiotic use in the PICU. Future work will determine optimal strategies for wider-scale dissemination of diagnostic stewardship in this setting while monitoring patient safety and balancing measures.
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Affiliation(s)
- Charlotte Z. Woods-Hill
- Division of Critical Care Medicine, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Elizabeth A. Colantuoni
- Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Danielle W. Koontz
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Annie Voskertchian
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Anping Xie
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Cary Thurm
- Children’s Hospital Association, Lenexa, Kansas
| | - Marlene R. Miller
- Rainbow Babies and Children’s Hospital, Cleveland, Ohio
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - James C. Fackler
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Aaron M. Milstone
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, Maryland
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Beck EJ, Hsieh YH, Fernandez RE, Dashler G, Egbert ER, Truelove SA, Garliss C, Wang R, Bloch EM, Shrestha R, Blankson J, Cox AL, Manabe YC, Kickler T, Rothman RE, Redd AD, Tobian AAR, Milstone AM, Quinn TC, Laeyendecker O. Differentiation of Individuals Previously Infected with and Vaccinated for SARS-CoV-2 in an Inner-City Emergency Department. J Clin Microbiol 2022. [PMID: 35044204 DOI: 10.1101/2021.10.13.21264968v1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2023] Open
Abstract
Emergency departments (EDs) can serve as surveillance sites for infectious diseases. The objective of this study was to determine the burden of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and to monitor the prevalence of vaccination against coronavirus disease 2019 (COVID-19) among patients attending an urban ED in Baltimore City. Using 1,914 samples of known exposure status, we developed an algorithm to differentiate previously infected, vaccinated, and unexposed individuals using a combination of antibody assays. We applied this testing algorithm to 4,360 samples from ED patients obtained in the spring of 2020 and 2021. Using multinomial logistic regression, we determined factors associated with infection and vaccination. For the algorithm, sensitivity and specificity for identifying vaccinated individuals were 100% and 99%, respectively, and 84% and 100% for previously infected individuals. Among the ED subjects, seroprevalence to SARS-CoV-2 increased from 2% to 24% between April 2020 and March 2021. Vaccination prevalence rose to 11% by mid-March 2021. Marked differences in burden of disease and vaccination coverage were seen by sex, race, and ethnicity. Hispanic patients, though accounting for 7% of the study population, had the highest relative burden of disease (17% of total infections) but with similar vaccination rates. Women and white individuals were more likely to be vaccinated than men or Black individuals. Individuals previously infected with SARS-CoV-2 can often be differentiated from vaccinated individuals using a serologic testing algorithm. The utility of this algorithm can aid in monitoring SARS-CoV-2 exposure and vaccination uptake frequencies and can potentially reflect gender, race, and ethnic health disparities.
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Affiliation(s)
- Evan J Beck
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Yu-Hsiang Hsieh
- Department of Emergency Medicine, Johns Hopkins University School of Medicinegrid.471401.7, Baltimore, Maryland, USA
| | - Reinaldo E Fernandez
- Department of Medicine, Johns Hopkins University School of Medicinegrid.471401.7, Baltimore, Maryland, USA
| | - Gaby Dashler
- Department of Emergency Medicine, Johns Hopkins University School of Medicinegrid.471401.7, Baltimore, Maryland, USA
| | - Emily R Egbert
- Department of Pediatrics, Johns Hopkins University School of Medicinegrid.471401.7, Baltimore, Maryland, USA
| | - Shawn A Truelove
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Caroline Garliss
- Department of Medicine, Johns Hopkins University School of Medicinegrid.471401.7, Baltimore, Maryland, USA
| | - Richard Wang
- Department of Emergency Medicine, Johns Hopkins University School of Medicinegrid.471401.7, Baltimore, Maryland, USA
| | - Evan M Bloch
- Department of Pathology, Johns Hopkins University School of Medicinegrid.471401.7, Baltimore, Maryland, USA
| | - Ruchee Shrestha
- Department of Pathology, Johns Hopkins University School of Medicinegrid.471401.7, Baltimore, Maryland, USA
| | - Joel Blankson
- Department of Medicine, Johns Hopkins University School of Medicinegrid.471401.7, Baltimore, Maryland, USA
| | - Andrea L Cox
- Department of Medicine, Johns Hopkins University School of Medicinegrid.471401.7, Baltimore, Maryland, USA
| | - Yukari C Manabe
- Department of Medicine, Johns Hopkins University School of Medicinegrid.471401.7, Baltimore, Maryland, USA
| | - Thomas Kickler
- Department of Pathology, Johns Hopkins University School of Medicinegrid.471401.7, Baltimore, Maryland, USA
| | - Richard E Rothman
- Department of Emergency Medicine, Johns Hopkins University School of Medicinegrid.471401.7, Baltimore, Maryland, USA
| | - Andrew D Redd
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
- Department of Medicine, Johns Hopkins University School of Medicinegrid.471401.7, Baltimore, Maryland, USA
| | - Aaron A R Tobian
- Department of Pathology, Johns Hopkins University School of Medicinegrid.471401.7, Baltimore, Maryland, USA
| | - Aaron M Milstone
- Department of Pediatrics, Johns Hopkins University School of Medicinegrid.471401.7, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Thomas C Quinn
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
- Department of Medicine, Johns Hopkins University School of Medicinegrid.471401.7, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Oliver Laeyendecker
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
- Department of Medicine, Johns Hopkins University School of Medicinegrid.471401.7, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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33
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Rider E, Ligon JA, Voskertchian A, Milstone AM, Toltzis P. Sampling Multiple Catheter Lumens to Improve Detection of Bloodstream Infection in Pediatric Oncology Patients. J Pediatr Hematol Oncol 2022; 44:e518-e520. [PMID: 34978782 PMCID: PMC8840984 DOI: 10.1097/mph.0000000000002278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 06/29/2021] [Indexed: 11/26/2022]
Abstract
Current guidelines recommend sampling each central-access lumen during the initial evaluation of febrile pediatric oncology patients. We investigated this recommendation's validity at centers implementing a diagnostic stewardship program to reduce blood cultures in critically ill children. Among 146 oncology patients admitted to the intensive care unit, there were 34 eligible blood culture-sets. Eleven (34%) sets yielded discordant results, most commonly cultivating a likely pathogen from one lumen and no growth from another. As hospitals move toward reducing testing overuse, these results emphasize the continued importance of culturing each central-access lumen to optimize the detection of bacteremia in the initial evaluation of critically ill pediatric oncology patients.
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Affiliation(s)
- Erica Rider
- Department of Pediatrics, Rainbow Babies and Children’s Hospital, Cleveland, OH
| | - John A. Ligon
- Department of Oncology, Division of Pediatric Oncology, Johns Hopkins University School of Medicine, Baltimore, MD
- Pediatric Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States
| | - Annie Voskertchian
- Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Aaron M. Milstone
- Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Philip Toltzis
- Department of Pediatrics, Rainbow Babies and Children’s Hospital, Cleveland, OH
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Mody L, Akinboyo IC, Babcock HM, Bischoff WE, Cheng VCC, Chiotos K, Claeys KC, Coffey KC, Diekema DJ, Donskey CJ, Ellingson KD, Gilmartin HM, Gohil SK, Harris AD, Keller SC, Klein EY, Krein SL, Kwon JH, Lauring AS, Livorsi DJ, Lofgren ET, Merrill K, Milstone AM, Monsees EA, Morgan DJ, Perri LP, Pfeiffer CD, Rock C, Saint S, Sickbert-Bennett E, Skelton F, Suda KJ, Talbot TR, Vaughn VM, Weber DJ, Wiemken TL, Yassin MH, Ziegler MJ, Anderson DJ. Coronavirus disease 2019 (COVID-19) research agenda for healthcare epidemiology. Infect Control Hosp Epidemiol 2022; 43:156-166. [PMID: 33487199 PMCID: PMC8160487 DOI: 10.1017/ice.2021.25] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 01/07/2021] [Indexed: 02/07/2023]
Abstract
This SHEA white paper identifies knowledge gaps and challenges in healthcare epidemiology research related to coronavirus disease 2019 (COVID-19) with a focus on core principles of healthcare epidemiology. These gaps, revealed during the worst phases of the COVID-19 pandemic, are described in 10 sections: epidemiology, outbreak investigation, surveillance, isolation precaution practices, personal protective equipment (PPE), environmental contamination and disinfection, drug and supply shortages, antimicrobial stewardship, healthcare personnel (HCP) occupational safety, and return to work policies. Each section highlights three critical healthcare epidemiology research questions with detailed description provided in supplementary materials. This research agenda calls for translational studies from laboratory-based basic science research to well-designed, large-scale studies and health outcomes research. Research gaps and challenges related to nursing homes and social disparities are included. Collaborations across various disciplines, expertise and across diverse geographic locations will be critical.
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Affiliation(s)
- Lona Mody
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, United States
- Geriatrics Research Education and Clinical Center, Veterans’ Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, United States
| | - Ibukunoluwa C. Akinboyo
- Division of Infectious Diseases, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, United States
| | - Hilary M. Babcock
- Washington University School of Medicine, St. Louis, Missouri, United States
| | - Werner E. Bischoff
- Wake Forest School of Medicine, Winston Salem, North Carolina, United States
| | - Vincent Chi-Chung Cheng
- Department of Microbiology, Queen Mary Hospital, Hong Kong Special Administrative Region, China
- Infection Control Team, Queen Mary Hospital, Hong Kong West Cluster, Hong Kong Special Administrative Region, China
| | - Kathleen Chiotos
- Division of Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Kimberly C. Claeys
- University of Maryland School of Pharmacy, Baltimore, Maryland, United States
| | - K. C. Coffey
- University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - Daniel J. Diekema
- Carver College of Medicine, University of Iowa, Iowa City, Iowa, United States
| | - Curtis J. Donskey
- Infectious Diseases Section, Louis Stokes Cleveland Veterans’ Affairs Medical Center, Cleveland, Ohio, United States
- Case Western Reserve University School of Medicine, Cleveland, Ohio, United States
| | - Katherine D. Ellingson
- Department of Epidemiology and Biostatistics, College of Public Health, University of Arizona, Tucson, Arizona, United States
| | - Heather M. Gilmartin
- Veterans’ Affairs Eastern Colorado Healthcare System, Aurora, Colorado, United States
- Colorado School of Public Health, University of Colorado, Aurora, Colorado, United States
| | - Shruti K. Gohil
- Division of Infectious Diseases, University of California Irvine School of Medicine, Irvine, California, United States
- Epidemiology and Infection Prevention, UC Irvine Health, Irvine, California, United States
| | - Anthony D. Harris
- University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - Sara C. Keller
- Division of Infectious Diseases, John Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Eili Y. Klein
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, Maryland, Unites States
| | - Sarah L. Krein
- Veterans’ Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor, Michigan, United States
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, United States
| | - Jennie H Kwon
- Washington University School of Medicine, St. Louis, Missouri, United States
| | - Adam S. Lauring
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, United States
| | - Daniel J. Livorsi
- Carver College of Medicine, University of Iowa, Iowa City, Iowa, United States
- Iowa City Veterans’ Affairs Health Care System, Iowa City, Iowa, United States
| | - Eric T. Lofgren
- Paul G. Allen School for Global Animal Health, Washington State University, Pullman, Washington, United States
| | | | - Aaron M. Milstone
- Division of Pediatric Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Elizabeth A. Monsees
- Children’s Mercy Kansas City, Kansas City, Missouri, United States
- University of Missouri–Kansas City School of Medicine, Kansas City, Missouri, United States
| | - Daniel J. Morgan
- University of Maryland School of Medicine, Baltimore, Maryland, United States
- Veterans’ Affairs Maryland Healthcare System, Baltimore, Maryland, United States
| | - Luci P. Perri
- Infection Control Results, Wingate, North Carolina, United States
| | - Christopher D. Pfeiffer
- Veterans’ Affairs Portland Health Care System, Portland, Oregon, United States
- Oregon Health & Science University, Portland, Oregon, United States
| | - Clare Rock
- Division of Infectious Diseases, John Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Sanjay Saint
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, United States
- Veterans’ Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, United States
| | - Emily Sickbert-Bennett
- Department of Infection Prevention, University of North Carolina Medical Center, Chapel Hill, North Carolina, United States
| | - Felicia Skelton
- Michael E. DeBakey Veterans’ Affairs Medical Center, Houston, Texas, United States
- H. Ben Taub Department of Physical Medicine & Rehabilitation, Baylor College of Medicine, Houston, Texas, United States
| | - Katie J. Suda
- Center for Health Equity Research and Promotion, Veterans’ Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, United States
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Thomas R. Talbot
- Vanderbilt University School of Medicine, Nashville, Tennessee, United States
| | - Valerie M. Vaughn
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - David J. Weber
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| | - Timothy L. Wiemken
- Division of Infectious Diseases, Allergy, and Immunology, Department of Medicine, Saint Louis University School of Medicine, St Louis, Missouri, United States
| | - Mohamed H. Yassin
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
- Infectious Diseases and Microbiology, Graduate School of Public Health, University of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Matthew J. Ziegler
- Infectious Diseases Division, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Deverick J. Anderson
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University School of Medicine, Durham, North Carolina, United States
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35
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Debes AK, Xiao S, Egbert ER, Caturegli P, Sitaras I, Pekosz A, Milstone AM. Comparison of total and neutralizing SARS-CoV-2 spike antibodies against omicron and other variants in paired samples after two or three doses of mRNA vaccine. medRxiv 2022:2022.01.26.22269819. [PMID: 35132427 PMCID: PMC8820679 DOI: 10.1101/2022.01.26.22269819] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Recognizing that anti-SARS-CoV-2 antibody levels wane over time following the 2-dose SARS-CoV-2 mRNA series, the FDA approved a booster dose for people greater than 12 years old. Limited data exist on whether a booster dose of the mRNA vaccine results in greater antibody protection than the primary series. We examined total and neutralizing antibodies to the spike protein of SARS-CoV-2, and neutralizing antibodies against Washington-1 (WA-1) and variants of concern (VOC) including Beta, Delta and Omicron in a longitudinal cohort. Healthcare workers (HWs) were included in the analysis if serum was collected 1) within 14-44 days post-dose2 of an mRNA SARS-CoV-2 vaccine (Timepoint 1, TP1), or 2) at least 8 months post-dose2 (Timepoint 2, TP2), or 3) within 14-44 days following mRNA booster (Timepoint 3, TP3). HWs with prior covid-positive PCR were excluded. We found that there is little to no neutralizing capability following a 2-dose mRNA vaccine series against the omicron variant, and neutralizing capacity to any variant strain tested has been lost by 8-months post two-dose vaccination series. However, the mRNA booster series eliminates the immune escape observed by the omicron variant with the two-dose series. Neutralizing titers were significantly higher for all variants post-boost compared to the titers post two-dose series. The longitudinal nature of our cohort facilitated the analysis of paired samples pre and post boost, showing a greater than 15-fold increase in neutralization against omicron post-boost in these paired samples. An mRNA booster dose provides greater quantity and quality of antibodies compared to a two-dose regimen and is critical to provide any protection against the omicron variant.
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Affiliation(s)
- Amanda K. Debes
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Shaoming Xiao
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Emily R. Egbert
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Ioannis Sitaras
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Andrew Pekosz
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aaron M. Milstone
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
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36
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Zhong D, Xiao S, Debes AK, Egbert ER, Caturegli P, Colantuoni E, Milstone AM. Durability of Antibody Levels After Vaccination With mRNA SARS-CoV-2 Vaccine in Individuals With or Without Prior Infection. JAMA 2021; 326:2524-2526. [PMID: 34724529 PMCID: PMC8561429 DOI: 10.1001/jama.2021.19996] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 10/21/2021] [Indexed: 12/14/2022]
Affiliation(s)
- Diana Zhong
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Shaoming Xiao
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Emily R. Egbert
- Johns Hopkins University School of Medicine, Baltimore, Maryland
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Rock C, Perlmutter R, Blythe D, Bork J, Claeys K, Cosgrove SE, Dzintars K, Fabre V, Harris AD, Heil E, Hsu YJ, Keller S, Maragakis LL, Milstone AM, Morgan DJ, Dullabh P, Ubri PS, Rotondo C, Brooks R, Leekha S. Impact of Statewide Prevention and Reduction of Clostridioides difficile (SPARC), a Maryland public health-academic collaborative: an evaluation of a quality improvement intervention. BMJ Qual Saf 2021; 31:153-162. [PMID: 34887357 PMCID: PMC8784990 DOI: 10.1136/bmjqs-2021-014014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 11/04/2021] [Indexed: 11/04/2022]
Abstract
To evaluate changes in Clostridioides difficile incidence rates for Maryland hospitals that participated in the Statewide Prevention and Reduction of C. difficile (SPARC) collaborative. Pre-post, difference-in-difference analysis of non-randomised intervention using four quarters of preintervention and six quarters of postintervention National Healthcare Safety Network data for SPARC hospitals (April 2017 to March 2020) and 10 quarters for control hospitals (October 2017 to March 2020). Mixed-effects negative binomial models were used to assess changes over time. Process evaluation using hospital intervention implementation plans, assessments and interviews with staff at eight SPARC hospitals. Maryland, USA. All Maryland acute care hospitals; 12 intervention and 36 control hospitals. Participation in SPARC, a public health-academic collaborative made available to Maryland hospitals, with staggered enrolment between June 2018 and August 2019. Hospitals with higher C. difficile rates were recruited via email and phone. SPARC included assessments, feedback reports and ongoing technical assistance. Primary outcomes were C. difficile incidence rate measured as the quarterly number of C. difficile infections per 10 000 patient-days (outcome measure) and SPARC intervention hospitals' experiences participating in the collaborative (process measures). SPARC invited 13 hospitals to participate in the intervention, with 92% (n=12) participating. The 36 hospitals that did not participate served as control hospitals. SPARC hospitals were associated with 45% greater C. difficile reduction as compared with control hospitals (incidence rate ratio=0.55, 95% CI 0.35 to 0.88, p=0.012). Key SPARC activities, including access to trusted external experts, technical assistance, multidisciplinary collaboration, an accountability structure, peer-to-peer learning opportunities and educational resources, were associated with hospitals reporting positive experiences with SPARC. SPARC intervention hospitals experienced 45% greater reduction in C. difficile rates than control hospitals. A public health-academic collaborative might help reduce C. difficile and other hospital-acquired infections in individual hospitals and at state or regional levels.
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Affiliation(s)
- Clare Rock
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rebecca Perlmutter
- Emerging Infections Program, Maryland Department of Health, Baltimore, Maryland, USA
| | - David Blythe
- Emerging Infections Program, Maryland Department of Health, Baltimore, Maryland, USA
| | - Jacqueline Bork
- Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Kimberly Claeys
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Sara E Cosgrove
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kate Dzintars
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Valeria Fabre
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Anthony D Harris
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Emily Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Yea-Jen Hsu
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sara Keller
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lisa L Maragakis
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Aaron M Milstone
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Daniel J Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA.,VA Maryland Health Care System, Baltimore, Maryland, USA
| | | | | | | | - Richard Brooks
- Emerging Infections Program, Maryland Department of Health, Baltimore, Maryland, USA.,Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Surbhi Leekha
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
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38
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Debes AK, Xiao S, Colantuoni E, Egbert ER, Caturegli P, Gadala A, Milstone AM. Association of Vaccine Type and Prior SARS-CoV-2 Infection With Symptoms and Antibody Measurements Following Vaccination Among Health Care Workers. JAMA Intern Med 2021; 181:1660-1662. [PMID: 34398173 PMCID: PMC8369424 DOI: 10.1001/jamainternmed.2021.4580] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This cohort study evaluates symptoms following vaccination and antibody measurements in hospital workers who received an mRNA SARS-CoV-2 vaccine and had prior SARS-CoV-2 infection.
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Affiliation(s)
- Amanda K Debes
- Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Shaoming Xiao
- Johns Hopkins School of Public Health, Baltimore, Maryland
| | | | - Emily R Egbert
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | - Aaron M Milstone
- Johns Hopkins School of Public Health, Baltimore, Maryland.,Johns Hopkins University School of Medicine, Baltimore, Maryland.,Johns Hopkins Health System, Baltimore, Maryland
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Lam B, Kung YJ, Lin J, Tseng SH, Tsai YC, He L, Castiglione G, Egbert E, Duh EJ, Bloch EM, Tobian AAR, Milstone AM, Roden RBS, Wu TC, Hung CF. In vivo characterization of emerging SARS-CoV-2 variant infectivity and human antibody escape potential. Cell Rep 2021; 37:109838. [PMID: 34648735 PMCID: PMC8491932 DOI: 10.1016/j.celrep.2021.109838] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/30/2021] [Accepted: 09/23/2021] [Indexed: 01/16/2023] Open
Abstract
As severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spreads, variants with enhanced virulence and transmissibility have emerged. Although in vitro systems allow rapid characterization, they do not fully recapitulate the dynamic interaction of virions and neutralizing antibodies in the airway. Here, we demonstrate that the N501Y variant permits respiratory infection in unmodified mice. We utilize N501Y to survey in vivo pseudovirus infection dynamics and susceptibility to reinfection with the L452R (Los Angeles), K417N + E484K (South Africa), and L452R + K417N + E484Q (India) variants. Human coronavirus disease 2019 (COVID-19)+ or vaccinated antibody isotypes, titers, variant receptor binding domain (RBD) binding, and neutralization potential are studied, revealing numerous significant correlations. Immune escape of the K417N + E484K variant is observed because infection can be appreciated in the nasopharynx, but not lungs, of mice transferred with low-antibody-tier plasma. Conversely, near-complete protection is observed in animals receiving high-antibody-tier plasma, a phenomenon that can only be appreciated in vivo.
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Affiliation(s)
- Brandon Lam
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; Graduate Program in Immunology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Yu Jui Kung
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - John Lin
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Ssu-Hsueh Tseng
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Ya Chea Tsai
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Liangmei He
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Gianni Castiglione
- Department of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Emily Egbert
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Elia J Duh
- Department of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Evan M Bloch
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Aaron A R Tobian
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Aaron M Milstone
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA; Department of Hospital Epidemiology and Infection Control, The Johns Hopkins Hospital, Baltimore, MD 21205, USA
| | - Richard B S Roden
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; Department of Obstetrics and Gynecology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Tzyy-Choou Wu
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; Department of Obstetrics and Gynecology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; Molecular Microbiology and Immunology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Chien-Fu Hung
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
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Beck EJ, Hsieh YH, Fernandez RE, Dashler G, Egbert ER, Truelove SA, Garliss C, Wang R, Bloch EM, Shrestha R, Blankson J, Cox AL, Manabe YC, Kickler T, Rothman RE, Redd AD, Tobian AA, Milstone AM, Quinn TC, Laeyendecker O. Differentiation of SARS-CoV-2 naturally infected and vaccinated individuals in an inner-city emergency department. medRxiv 2021. [PMID: 34671778 PMCID: PMC8528087 DOI: 10.1101/2021.10.13.21264968] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background Emergency Departments (EDs) can serve as surveillance sites for infectious diseases. Our purpose was to determine the burden of SARS-CoV-2 infection and prevalence of vaccination against COVID-19 among patients attending an urban ED in Baltimore City. Methods Using 1914 samples of known exposure status, we developed an algorithm to differentiate previously infected, vaccinated, and unexposed individuals using a combination of antibody assays. We applied this testing algorithm to 4360 samples ED patients obtained in the springs of 2020 and 2021. Using multinomial logistic regression, we determined factors associated with infection and vaccination. Results For the algorithm, sensitivity and specificity for identifying vaccinated individuals was 100% and 99%, respectively, and 84% and 100% for naturally infected individuals. Among the ED subjects, seroprevalence to SARS-CoV-2 increased from 2% to 24% between April 2020 and March 2021. Vaccination prevalence rose to 11% by mid-March 2021. Marked differences in burden of disease and vaccination coverage were seen by sex, race, and ethnicity. Hispanic patients, though 7% of the study population, had the highest relative burden of disease (17% of total infections) but similar vaccination rates. Women and White individuals were more likely to be vaccinated than men or Black individuals (adjusted odds ratios [aOR] 1.35 [95% CI: 1.02, 1.80] and aOR 2.26 [95% CI: 1.67, 3.07], respectively). Conclusions Individuals previously infected with SARS-CoV-2 can be differentiated from vaccinated individuals using a serologic testing algorithm. SARS-CoV-2 exposure and vaccination uptake frequencies reflect gender, race and ethnic health disparities in this urban context. Summary Using an antibody testing algorithm, we distinguished between immune responses from SARS-CoV-2-infected and vaccinated individuals. When applied to blood samples from an emergency department in Baltimore, disparities in disease burden and vaccine uptake by sex, race, and ethnicity were identified.
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Rock C, Hsu YJ, Curless MS, Carroll KC, Howard TR, Carson KA, Cummings S, Anderson M, Milstone AM, Maragakis LL. Ultraviolet-C Light Evaluation as Adjunct Disinfection to Remove Multi-Drug Resistant Organisms. Clin Infect Dis 2021; 75:35-40. [PMID: 34636853 PMCID: PMC9402681 DOI: 10.1093/cid/ciab896] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Indexed: 11/24/2022] Open
Abstract
Background Our objective was to determine if the addition of ultraviolet-C (UV-C) light to daily and discharge patient room cleaning reduces healthcare-associated infection rates of vancomycin-resistant enterococci (VRE) and Clostridioides difficile in immunocompromised adults. Methods We performed a cluster randomized crossover control trial in 4 cancer and 1 solid organ transplant in-patient units at the Johns Hopkins Hospital, Baltimore, Maryland. For study year 1, each unit was randomized to intervention of UV-C light plus standard environmental cleaning or control of standard environmental cleaning, followed by a 5-week washout period. In study year 2, units switched assignments. The outcomes were healthcare-associated rates of VRE or C. difficile. Statistical inference used a two-stage approach recommended for cluster-randomized trials with <15 clusters/arm. Results In total, 302 new VRE infections were observed during 45787 at risk patient-days. The incidence in control and intervention groups was 6.68 and 6.52 per 1000 patient-days respectively; the unadjusted incidence rate ratio (IRR) was 0.98 (95% confidence interval [CI], .78 − 1.22; P = .54). There were 84 new C. difficile infections observed during 26118 at risk patient-days. The incidence in control and intervention periods was 2.64 and 3.78 per 1000 patient-days respectively; the unadjusted IRR was 1.43 (95% CI, .93 − 2.21; P = .98). Conclusions When used daily and at post discharge in addition to standard environmental cleaning, UV-C disinfection did not reduce VRE or C. difficile infection rates in cancer and solid organ transplant units.
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Affiliation(s)
- Clare Rock
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States.,Department of Hospital Epidemiology and Infection Control, The Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Yea-Jen Hsu
- Department of Health Policy and Management, Johns Hopkins Bloomberg of School of Public Health, Baltimore, Maryland, United States
| | - Melanie S Curless
- Department of Hospital Epidemiology and Infection Control, The Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Karen C Carroll
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Tracy Ross Howard
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Kathryn A Carson
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States
| | - Stephanie Cummings
- Department of Hospital Epidemiology and Infection Control, The Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Michael Anderson
- Department of Hospital Epidemiology and Infection Control, The Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Aaron M Milstone
- Department of Hospital Epidemiology and Infection Control, The Johns Hopkins Hospital, Baltimore, Maryland, United States.,Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Lisa L Maragakis
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States.,Department of Hospital Epidemiology and Infection Control, The Johns Hopkins Hospital, Baltimore, Maryland, United States
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Zhao N, Khamash DF, Koh H, Voskertchian A, Egbert E, Mongodin EF, White JR, Hittle L, Colantuoni E, Milstone AM. Low Diversity in Nasal Microbiome Associated With Staphylococcus aureus Colonization and Bloodstream Infections in Hospitalized Neonates. Open Forum Infect Dis 2021; 8:ofab475. [PMID: 34651052 PMCID: PMC8507450 DOI: 10.1093/ofid/ofab475] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 09/14/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Staphylococcus aureus is a leading cause of infectious morbidity and mortality in neonates. Few data exist on the association of the nasal microbiome and susceptibility to neonatal S. aureus colonization and infection. METHODS We performed 2 matched case-control studies (colonization cohort-neonates who did and did not acquire S. aureus colonization; bacteremia cohort-neonates who did [colonized neonates] and did not [controls] acquire S. aureus colonization and neonates with S. aureus bacteremia [bacteremic neonantes]). Neonates in 2 intensive care units were enrolled and matched on week of life at time of colonization or infection. Nasal samples were collected weekly until discharge and cultured for S. aureus, and the nasal microbiome was characterized using 16S rRNA gene sequencing. RESULTS In the colonization cohort, 43 S. aureus-colonized neonates were matched to 82 controls. At 1 week of life, neonates who acquired S. aureus colonization had lower alpha diversity (Wilcoxon rank-sum test P < .05) and differed in beta diversity (omnibus MiRKAT P = .002) even after adjusting for birth weight (P = .01). The bacteremia cohort included 10 neonates, of whom 80% developed bacteremia within 4 weeks of birth and 70% had positive S. aureus cultures within a few days of bacteremia. Neonates with bacteremia had an increased relative abundance of S. aureus sequences and lower alpha diversity measures compared with colonized neonates and controls. CONCLUSIONS The association of increased S. aureus abundance and decrease of microbiome diversity suggest the need for interventions targeting the nasal microbiome to prevent S. aureus disease in vulnerable neonates.
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Affiliation(s)
- Ni Zhao
- Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Dina F Khamash
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Hyunwook Koh
- Deptartment of Applied Mathematics & Statistics, The State University of New York, Korea (SUNY Korea), Incheon, South Korea
| | - Annie Voskertchian
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Emily Egbert
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Emmanuel F Mongodin
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | | | | | - Elizabeth Colantuoni
- Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Aaron M Milstone
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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43
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Woods-Hill CZ, Koontz DW, Voskertchian A, Xie A, Shea J, Miller MR, Fackler JC, Milstone AM. Consensus Recommendations for Blood Culture Use in Critically Ill Children Using a Modified Delphi Approach. Pediatr Crit Care Med 2021; 22:774-784. [PMID: 33899804 PMCID: PMC8416691 DOI: 10.1097/pcc.0000000000002749] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Blood cultures are fundamental in evaluating for sepsis, but excessive cultures can lead to false-positive results and unnecessary antibiotics. Our objective was to create consensus recommendations focusing on when to safely avoid blood cultures in PICU patients. DESIGN A panel of 29 multidisciplinary experts engaged in a two-part modified Delphi process. Round 1 consisted of a literature summary and an electronic survey sent to invited participants. In the survey, participants rated a series of recommendations about when to avoid blood cultures on five-point Likert scale. Consensus was achieved for the recommendation(s) if 75% of respondents chose a score of 4 or 5, and these were included in the final recommendations. Any recommendations that did not meet these a priori criteria for consensus were discussed during the in-person expert panel review (Round 2). Round 2 was facilitated by an independent expert in consensus methodology. After a review of the survey results, comments from round 1, and group discussion, the panelists voted on these recommendations in real-time. SETTING Experts' institutions; in-person discussion in Baltimore, MD. SUBJECTS Experts in pediatric critical care, infectious diseases, nephrology, oncology, and laboratory medicine. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of the 27 original recommendations, 18 met criteria for achieving consensus in Round 1; some were modified for clarity or condensed from multiple into single recommendations during Round 2. The remaining nine recommendations were discussed and modified until consensus was achieved during Round 2, which had 26 real-time voting participants. The final document contains 19 recommendations. CONCLUSIONS Using a modified Delphi process, we created consensus recommendations on when to avoid blood cultures and prevent overuse in the PICU. These recommendations are a critical step in disseminating diagnostic stewardship on a wider scale in critically ill children.
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Affiliation(s)
- Charlotte Z Woods-Hill
- Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Danielle W Koontz
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Annie Voskertchian
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Anping Xie
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Judy Shea
- Division of General Internal Medicine, Department of Medicine and Leonard Davis Institute of Health Economics
| | - Marlene R Miller
- Rainbow Babies and Children’s Hospital
- Case Western Reserve University School of Medicine
- Johns Hopkins Bloomberg School of Public Health
| | - James C Fackler
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Aaron M Milstone
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
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Ambalam V, Sick-Samuels AC, Johnson J, Colantuoni E, Gadala A, Rock C, Milstone AM. Impact of postnatal age on neonatal intensive care unit bloodstream infection reporting. Am J Infect Control 2021; 49:1191-1193. [PMID: 33819494 DOI: 10.1016/j.ajic.2021.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 03/24/2021] [Accepted: 03/24/2021] [Indexed: 11/15/2022]
Abstract
Due to their short- and long-term impact on patients in the neonatal intensive care unit (NICU), bloodstream infections are a closely monitored quality measure. NICU infection rates are risk-adjusted for birth weight, but not postnatal age. Our findings suggest that infection rates are not constant over time in neonates with long NICU lengths of stay and adjusting for postnatal age in addition to birth weight may improve unit comparisons.
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Affiliation(s)
- Viraj Ambalam
- Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University, Baltimore, MD
| | - Anna C Sick-Samuels
- Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University, Baltimore, MD; Department of Healthcare Epidemiology and Infection Prevention, Johns Hopkins Health System, Baltimore, MD
| | - Julia Johnson
- Department of Pediatrics, Division of Neonatology, Johns Hopkins University, Baltimore, MD
| | - Elizabeth Colantuoni
- Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Avinash Gadala
- Department of Healthcare Epidemiology and Infection Prevention, Johns Hopkins Health System, Baltimore, MD
| | - Clare Rock
- Department of Healthcare Epidemiology and Infection Prevention, Johns Hopkins Health System, Baltimore, MD; Department of Medicine, Division of Infectious Diseases, Johns Hopkins University, Baltimore, MD
| | - Aaron M Milstone
- Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University, Baltimore, MD; Department of Healthcare Epidemiology and Infection Prevention, Johns Hopkins Health System, Baltimore, MD.
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45
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Booth LD, Sick-Samuels AC, Milstone AM, Fackler JC, Gnazzo LK, Stockwell DC. Culture Ordering for Patients with New-onset Fever: A Survey of Pediatric Intensive Care Unit Clinician Practices. Pediatr Qual Saf 2021; 6:e463. [PMID: 34476315 PMCID: PMC8389917 DOI: 10.1097/pq9.0000000000000463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 04/02/2021] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Accurate assessment of infection in critically ill patients is vital to their care. Both indiscretion and under-utilization of diagnostic microbiology testing can contribute to inappropriate antibiotic administration or delays in diagnosis. However, indiscretion in diagnostic microbiology cultures may also lead to unnecessary tests that, if false-positive, would incur additional costs and unhelpful evaluations. This quality improvement project objective was to assess pediatric intensive care unit (PICU) clinicians' attitudes and practices around the microbiology work-up for patients with new-onset fever. METHODS We developed and conducted a self-administered electronic survey of PICU clinicians at a single institution. The survey included 7 common clinical vignettes of PICU patients with new-onset fever and asked participants whether they would obtain central line blood cultures, peripheral blood cultures, respiratory aspirate cultures, cerebrospinal fluid cultures, urine cultures, and/or urinalyses. RESULTS Forty-seven of 54 clinicians (87%) completed the survey. Diagnostic specimen ordering practices were notably heterogeneous. Respondents unanimously favored a decision-support algorithm to guide culture specimen ordering practices for PICU patients with fever (100%, N = 47). A majority (91.5%, N = 43) indicated that a decision-support algorithm would be a means to align PICU and consulting care teams when ordering culture specimens for patients with fever. CONCLUSION This survey revealed variability of diagnostic specimen ordering practices for patients with new fever, supporting an opportunity to standardize practices. Clinicians favored a decision-support tool and thought that it would help align patient management between clinical team members. The results will be used to inform future diagnostic stewardship efforts.
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Affiliation(s)
- Lauren D. Booth
- From the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Md
| | - Anna C. Sick-Samuels
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Md
- Department of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, Md
| | - Aaron M. Milstone
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Md
- Department of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, Md
| | - James C. Fackler
- From the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Md
| | | | - David C. Stockwell
- From the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Md
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Johnson J, Robinson ML, Rajput UC, Valvi C, Kinikar A, Parikh TB, Vaidya U, Malwade S, Agarkhedkar S, Randive B, Kadam A, Smith RM, Westercamp M, Mave V, Gupta A, Milstone AM, Manabe YC. High Burden of Bloodstream Infections Associated With Antimicrobial Resistance and Mortality in the Neonatal Intensive Care Unit in Pune, India. Clin Infect Dis 2021; 73:271-280. [PMID: 32421763 PMCID: PMC8282256 DOI: 10.1093/cid/ciaa554] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 05/08/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Antimicrobial resistance (AMR) is a growing threat to newborns in low- and middle-income countries (LMIC). METHODS We performed a prospective cohort study in 3 tertiary neonatal intensive care units (NICUs) in Pune, India, to describe the epidemiology of neonatal bloodstream infections (BSIs). All neonates admitted to the NICU were enrolled. The primary outcome was BSI, defined as positive blood culture. Early-onset BSI was defined as BSI on day of life (DOL) 0-2 and late-onset BSI on DOL 3 or later. RESULTS From 1 May 2017 until 30 April 2018, 4073 neonates were enrolled. Among at-risk neonates, 55 (1.6%) developed early-onset BSI and 176 (5.5%) developed late-onset BSI. The majority of BSIs were caused by gram-negative bacteria (GNB; 58%); among GNB, 61 (45%) were resistant to carbapenems. Klebsiella spp. (n = 53, 23%) were the most common cause of BSI. Compared with neonates without BSI, all-cause mortality was higher among neonates with early-onset BSI (31% vs 10%, P < .001) and late-onset BSI (24% vs 7%, P < .001). Non-low-birth-weight neonates with late-onset BSI had the greatest excess in mortality (22% vs 3%, P < .001). CONCLUSIONS In our cohort, neonatal BSIs were most commonly caused by GNB, with a high prevalence of AMR, and were associated with high mortality, even in term neonates. Effective interventions are urgently needed to reduce the burden of BSI and death due to AMR GNB in hospitalized neonates in LMIC.
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Affiliation(s)
- Julia Johnson
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Matthew L Robinson
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Uday C Rajput
- Department of Pediatrics, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Chhaya Valvi
- Department of Pediatrics, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Aarti Kinikar
- Department of Pediatrics, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Tushar B Parikh
- Division of Neonatology, Department of Pediatrics, King Edward Memorial Hospital, Pune, India
| | - Umesh Vaidya
- Division of Neonatology, Department of Pediatrics, King Edward Memorial Hospital, Pune, India
| | - Sudhir Malwade
- Department of Pediatrics, Dr D. Y. Patil Medical College, Pune, India
| | | | - Bharat Randive
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - Abhay Kadam
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - Rachel M Smith
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Vidya Mave
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - Amita Gupta
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Aaron M Milstone
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yukari C Manabe
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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47
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Egbert ER, Xiao S, Colantuoni E, Caturegli P, Gadala A, Milstone AM, Debes AK. Durability of Spike Immunoglobin G Antibodies to SARS-CoV-2 Among Health Care Workers With Prior Infection. JAMA Netw Open 2021; 4:e2123256. [PMID: 34459910 PMCID: PMC8406077 DOI: 10.1001/jamanetworkopen.2021.23256] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
This cohort study examines the durability of spike antibodies to SARS-CoV-2 among a cohort of US health workers.
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Affiliation(s)
- Emily R. Egbert
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Shaoming Xiao
- Johns Hopkins School of Public Health, Baltimore, Maryland
| | | | | | - Avinash Gadala
- Johns Hopkins University School of Medicine, Baltimore, Maryland
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Zerr DM, Milstone AM, Adler AL, Dvorak CC, Fisher BT, Sung L. Reply to Are we certain that chlorhexidine gluconate bathing is not beneficial in deducing central line associated blood stream infections among children with cancer or undergoing hematopoietic stem cell transplantation? Cancer 2021; 127:2813-2814. [PMID: 33945641 DOI: 10.1002/cncr.33570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 02/19/2021] [Indexed: 01/18/2023]
Affiliation(s)
| | - Aaron M Milstone
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Amanda L Adler
- Seattle Children's Research Institute, Seattle, Washington
| | | | | | - Lillian Sung
- Hospital for Sick Children, Toronto, Ontario, Canada
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49
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Jones G, Amoah J, Klein EY, Leeman H, Smith A, Levin S, Milstone AM, Dzintars K, Cosgrove SE, Fabre V. Development of an Electronic Algorithm to Identify in Real Time Adults Hospitalized With Suspected Community-Acquired Pneumonia. Open Forum Infect Dis 2021; 8:ofab291. [PMID: 34189181 PMCID: PMC8231365 DOI: 10.1093/ofid/ofab291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 06/01/2021] [Indexed: 11/12/2022] Open
Abstract
Background Community-acquired pneumonia (CAP) is a major driver of hospital antibiotic use. Efficient methods to identify patients treated for CAP in real time using the electronic health record (EHR) are needed. Automated identification of these patients could facilitate systematic tracking, intervention, and feedback on CAP-specific metrics such as appropriate antibiotic choice and duration. Methods Using retrospective data, we identified suspected CAP cases by searching for patients who received CAP antibiotics AND had an admitting International Classification of Diseases, Tenth Revision (ICD-10) code for pneumonia OR chest imaging within 24 hours OR bacterial urinary antigen testing within 48 hours of admission (denominator query). We subsequently explored different structured and natural language processing (NLP)–derived data from the EHR to identify CAP cases. We evaluated combinations of these electronic variables through receiver operating characteristic (ROC) curves to assess which best identified CAP cases compared to cases identified by manual chart review. Exclusion criteria were age <18 years, absolute neutrophil count <500 cells/mm3, and admission to an oncology unit. Results Compared to the gold standard of chart review, the area under the ROC curve to detect CAP was 0.63 (95% confidence interval [CI], .55–.72; P < .01) using structured data (ie, laboratory and vital signs) and 0.83 (95% CI, .77–.90; P < .01) when NLP-derived data from radiographic reports were included. The sensitivity and specificity of the latter model were 80% and 81%, respectively. Conclusions Creating an electronic tool that effectively identifies CAP cases in real time is possible, but its accuracy is dependent on NLP-derived radiographic data.
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Affiliation(s)
- George Jones
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joe Amoah
- Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Eili Y Klein
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Hannah Leeman
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Aria Smith
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Scott Levin
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Aaron M Milstone
- Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kathryn Dzintars
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Sara E Cosgrove
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Valeria Fabre
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Sick-Samuels AC, Linz M, Bergmann J, Fackler JC, Berenholtz SM, Ralston SL, Hoops K, Dwyer J, Colantuoni E, Milstone AM. Diagnostic Stewardship of Endotracheal Aspirate Cultures in a PICU. Pediatrics 2021; 147:peds.2020-1634. [PMID: 33827937 PMCID: PMC8086005 DOI: 10.1542/peds.2020-1634] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/04/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Clinicians commonly obtain endotracheal aspirate cultures (EACs) in the evaluation of suspected ventilator-associated infections. However, bacterial growth in EACs does not distinguish bacterial colonization from infection and may lead to overtreatment with antibiotics. We describe the development and impact of a clinical decision support algorithm to standardize the use of EACs from ventilated PICU patients. METHODS We monitored EAC use using a statistical process control chart. We compared the rate of EACs using Poisson regression and a quasi-experimental interrupted time series model and assessed clinical outcomes 1 year before and after introduction of the algorithm. RESULTS In the preintervention year, there were 557 EACs over 5092 ventilator days; after introduction of the algorithm, there were 234 EACs over 3654 ventilator days (an incident rate of 10.9 vs 6.5 per 100 ventilator days). There was a 41% decrease in the monthly rate of EACs (incidence rate ratio [IRR]: 0.59; 95% confidence interval [CI] 0.51-0.67; P < .001). The interrupted time series model revealed a preexisting 2% decline in the monthly culture rate (IRR: 0.98; 95% CI 0.97-1.0; P = .01), immediate 44% drop (IRR: 0.56; 95% CI 0.45-0.70; P = .02), and stable rate in the postintervention year (IRR: 1.03; 95% CI 0.99-1.07; P = .09). In-hospital mortality, hospital length of stay, 7-day readmissions, and All Patients Refined Diagnosis Related Group severity and mortality scores were stable. The estimated direct cost savings was $26 000 per year. CONCLUSIONS A clinical decision support algorithm standardizing EAC obtainment from ventilated PICU patients was associated with a sustained decline in the rate of EACs, without changes in mortality, readmissions, or length of stay.
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Affiliation(s)
- Anna C. Sick-Samuels
- Departments of Pediatrics and,Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, Maryland
| | - Matthew Linz
- New Jersey Medical School, Rutgers University, Newark, New Jersey; and
| | - Jules Bergmann
- Anesthesiology and Critical Care Medicine, School of Medicine, and
| | - James C. Fackler
- Anesthesiology and Critical Care Medicine, School of Medicine, and
| | - Sean M. Berenholtz
- Anesthesiology and Critical Care Medicine, School of Medicine, and,Departments of Health Policy and Management and,Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland
| | | | - Katherine Hoops
- Anesthesiology and Critical Care Medicine, School of Medicine, and
| | - Joe Dwyer
- Extra-Corporeal Membrane Oxygenation Services, Division of Respiratory Care, Departments of Pediatrics and
| | - Elizabeth Colantuoni
- Biostatistics, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Aaron M. Milstone
- Departments of Pediatrics and,Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, Maryland
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