Changing the culture of urine culturing: Utilizing Agile Implementation to improve diagnostic stewardship in the ICU

Over diagnosis of catheter-associated urinary tract infection (CAUTI) contributes to unnecessary and excessive antibiotic use, selection for resistant organisms, increased risk for Clostridiodes difficile infections, as well as a false elevation in CAUTI rates. Utilizing agile implementation to implement a urine culture algorithm achieved statistically significant reduction in CAUTI rates in a critical care unit resulting in sustainment and spread throughout the system.

1112. Improving Urine Culturing Practices in a Neurocritical Care Unit through a Multidisciplinary Algorithm-Based Approach

Background

Asymptomatic bacteriuria is common in hospitalized patients with urinary catheters. Inappropriate urine culturing as part of reflexive response to fever contributes to unnecessary and excessive antibiotic use, selection for resistant organisms, increased risk for Clostridium difficile infections, and false elevation in catheter-associated urinary tract infection (CAUTI) rates. This project aimed to implement an evidence-based urine culture algorithm in a 33-bed neurocritical care unit, a unit with a historically elevated CAUTI rate due to a high prevalence of noninfectious fever.

Methods

A multidisciplinary quality improvement project was initiated in August 2018 by the Infection Prevention, Quality and Safety, Neurocritical Care, Trauma, and Neurosurgery teams of an urban academic health center. The group implemented a urine culture algorithm that was adapted from the Infectious Diseases Society of America (IDSA) guidelines that clearly highlighted appropriate indications for sending urine cultures. The team agreed to utilize a urinalysis with reflex to culture as the preferred method to evaluate for CAUTI. The algorithm was implemented in September 2018. Outcomes were compared for pre-implementation (March-August 2018) and post-implementation (September 2018–February 2019).

Results

The NHSN CAUTI rate decreased from 4.52/1,000 Foley days to 1.27/1,000 Foley days (P-value 0.037) as a result of the intervention. The number of urine cultures ordered decreased by 82% after implementation. No cases of bacteremia or mortality secondary to a urinary source were identified during the project. Total days of antibiotic therapy for the unit was similar between the pre- and post-implementation time periods (P = 0.631).

Conclusion

Implementation of a urine culture algorithm in a neurocritical care unit resulted in reduced CAUTI rate with less financial and operational waste in unnecessary orders and treatment, without resulting in adverse events to patients as a result of missed diagnosis.

Disclosures

All authors: No reported disclosures.

Primary prevention of contact sports-related concussions in amateur athletes: a systematic review from the Eastern Association for the Surgery of Trauma

BACKGROUND

Awareness of the magnitude of contact sports-related concussions has risen exponentially in recent years. Our objective is to conduct a prospectively registered systematic review of the scientific evidence regarding interventions to prevent contact sports-related concussions.

METHODS

Using the Grading of Recommendations Assessment, Development, and Evaluation methodology, we performed a systematic review of the literature to answer seven population, intervention, comparator, and outcomes (PICO) questions regarding concussion education, head protective equipment, rules prohibiting high-risk activity and neck strengthening exercise for prevention of contact sports-related concussion in pediatric and adult amateur athletes. A query of MEDLINE, PubMed, Scopus, Cumulative Index of Nursing and Allied Health Literature, and Embase was performed. Letters to the editor, case reports, book chapters, and review articles were excluded, and all articles reviewed were written in English.

RESULTS

Thirty-one studies met the inclusion criteria and were applicable to our PICO questions. Conditional recommendations are made supporting preventive interventions concussion education and rules prohibiting high-risk activity for both pediatric and adult amateur athletes and neck strengthening exercise in adult amateur athletes. Strong recommendations are supported for head protective equipment in both pediatric and adult amateur athletes. Strong recommendations regarding newer football helmet technology in adult amateur athletes and rules governing the implementation of body-checking in youth ice hockey are supported.

CONCLUSION

Despite increasing scientific attention to sports-related concussion, studies evaluating preventive interventions remain relatively sparse. This systematic review serves as a call to focus research on primary prevention strategies for sports-related concussion.

LEVEL OF EVIDENCE

IV.

PROSPERO REGISTRATION NUMBER

#42016043019.

Guided imagery to improve functional outcomes post-anterior cruciate ligament repair: randomized-controlled pilot trial

Imagery can improve functional outcomes post-anterior cruciate ligament repair (ACLR). Research is needed to investigate potential mechanisms for this effect. The aim of this study was to (a) evaluate the effectiveness of an imagery intervention to improve functional outcomes post-ACLR, and (b) explore potential mechanisms. A randomized-controlled pilot trial was conducted. Participants were randomized to guided imagery and standard rehabilitation or standard rehabilitation alone (control). The primary outcome was knee strength 6-month post-operatively. Secondary outcomes were knee laxity at 6-months, and change in psychological (self-efficacy) and neurohormonal (adrenaline, noradrenaline, dopamine) variables. Participants (n=21; 62% male) were 34.86 (SD 8.84) years. Following the intervention, no statistical differences between groups for knee strength extension at 180°/s (t=-0.43, P=0.67), or at 60°/s (t=-0.72, P=0.48) were found. A statistically significant effect was found for knee laxity, F=4.67, P<0.05, mean difference of -3.02 (95% CI -4.44 to -1.60), favoring the intervention. No differences were found for self-efficacy; however, an overall effect was found for noradrenaline, F(1, 19) 19.65, P<0.001, η(2) =0.52, and dopamine, F(1, 19) 6.23, P=0.02, η(2) =0.29, favoring the intervention. This imagery intervention improved knee laxity and healing-related neurobiological factors.

A normal rate of cellular cholesterol removal can be mediated by plasma from a patient with familial lecithin-cholesterol acyltransferase (LCAT) deficiency

Lecithin-cholesterol acyltransferase (LCAT) is the major enzyme involved in the esterification of cholesterol in circulating plasma lipoproteins. In the present study, we describe the molecular defects in the LCAT gene and in lipoprotein metabolism of a 34-year-old patient presenting with features of classic familial LCAT deficiency. DNA sequencing revealed two separate point mutations in exon 3 of the patient's LCAT gene: a C to A substitution converting Tyr(83) to a Stop and a C to T transition converting an Arg(99) to a Cys. Digestion of patient PCR-amplified DNA with the restriction enzymes AccI and AciI established that the patient was a compound heterozygote for both mutations. In vitro expression of LCAT (Arg(99)-->Cys) in human embryonic kidney-293 cells demonstrated reduced expression, as well as reduced secretion and/or increased intracellular degradation of the mutant enzyme with significantly decreased alpha-LCAT specific activity, thus, establishing the functional significance of the LCAT (Arg(99)-->Cys) mutation. The plasma cholesterol esterification rate (CER, 2+/-0.3 nmol/ml/h), alpha-LCAT activity (2.9+/-0.1 nmol/ml/h) and LCAT concentration (0.3+/-0.1 microg/ml) were 2.9%, 2.3% and 6.1% that of normal subjects, respectively. Analysis of the patient's plasma lipid profile revealed reduced plasma concentrations of total cholesterol (111+/-0.5 mg/dl), HDL cholesterol (1.6+/-0.2 mg/dl), apolipoprotein (apo) A-I (52+/-4 mg/dl) and apo A-II (11+/-0.5 mg/dl). Nevertheless, for the first time, we demonstrate that the LCAT-deficient plasma is as efficient as control plasma in cholesterol efflux experiments performed with [(3)H]-cholesterol loaded fibroblasts. This result could explain the absence of premature atherosclerosis in this LCAT-deficient patient.

An ATP-binding cassette gene (ABCG5) from the ABCG (White) gene subfamily maps to human chromosome 2p21 in the region of the Sitosterolemia locus

We characterized a new human ATP-binding cassette (ABC) transporter gene that is highly expressed in the liver. The gene, ABCG5, contains 13 exons and encodes a 651 amino acid protein. The predicted protein is closely related to the Drosophila white gene and a human gene, ABCG1, which is induced by cholesterol. This subfamily of genes all have a single ATP-binding domain at the N-terminus and a single C-terminal set of transmembrane segments. ABCG5 maps to human chromosome 2p21, between the markers D2S117 and D2S119. The abundant expression of this gene in the liver suggests that the protein product has an important role in transport of specific molecule(s) into or out of this tissue.

Correction of the PNH defect by GPI-anchored protein transfer

Hemolytic anemia is a major feature of paroxysmal nocturnal hemoglobinuria (PNH). Intravascular red blood cell (RBC) destruction is caused by increased sensitivity of the abnormal erythrocyte to complement-mediated lysis, due to the GPI absence of a membrane-bound glycosylphosphatidylinositol (GPI)-linked protein, which functions as an inhibitor of reactive lysis (CD59). Both in vivo and in vitro models have suggested the feasibility of cell-to-cell transfer of GPI proteins, and patients with hemolysis could potentially benefit from transfer of CD59 to their deficient erythrocytes. We studied the ability of RBC components prepared from outdated packed RBC collections, as well as high-density lipoprotein (HDL) preparations, rich in CD55 and CD59, to promote protein transfer, as assessed by flow cytometry, immunoblotting, and susceptibility to complement-mediated lysis. By flow cytometry, CD55 and CD59 were present on RBC-derived microvesicles that stained with an antiglycophorin antibody Ab; in addition, soluble CD59 and CD55 were detected by immunoblot in soluble fractions eluated from RBC units stored for more than 35 days, but not in fresh blood. Both commercial HDL preparations and those prepared in our laboratory contained CD55 and CD59, as assayed by immunoblot. When RBC that were deficient (GPI)-anchored protein, obtained from five patients, with PNH were incubated with HDL preparations for 2 to 4 hours, there was significant transfer of both proteins to the cell surface, as demonstrated by flow cytometry. Washed RBC microvesicles, prepared by ultrasonification, also mediated transfer of GPI-linked proteins to deficient RBC. Pretreatment of microvesicles, RBC eluate preparations, and HDL with phosphatidylinositol-specific, phospholipase C, abrogated protein transfer to deficient cells, indicating that increased cell-associated CD55 and CD59 levels were related to insertion of the intact GPI moiety, rather than to simple adhesion. PNH RBC that were exposed to HDL, RBC eluate preparations, or microvesicles demonstrated decreased in vitro complement-mediated hemolysis in the Ham test. Transfer of GPI-linked proteins from soluble preparations containing CD55 and CD59 to PNH erythrocytes is feasible and may have clinical utility.

Closing the distance

Geriatric technicians work in the field, providing a link between care providers and rural elderly patients. In this study, the new role enhanced patient outcomes and satisfaction.

Deaths associated with warfarin in elderly patients

The four cases presented illustrate fatal errors in the management of elderly patients at different stages in the chain of their anticoagulation treatment. As indications for anticoagulation increase in the elderly, more care needs to be taken.

A multicenter study to evaluate a novel assay for quantitation of soluble interleukin 2 receptor in renal transplant recipients

The clinical utility of monitoring soluble interleukin 2 receptor (sIL-2R) as an indicator of immune stimulation in renal transplant patients was evaluated in a retrospective study at 3 centers. Serum samples (n = 2360) were obtained from 86 (17 living related donor, 69 cadaver) transplant recipients. The patients had received either triple therapy (n = 35) or antilymphocyte antibody induction therapy followed by triple therapy (n = 51). The mean period of postoperative observation was 118 days (range, 6-349 days). Serum sIL-2R concentrations were quantitated by an automated microparticle enzyme immunoassay (MEIA) (Abbott Diagnostics) in which sIL-2R was captured by 7G7/B6 monoclonal antibody-coated microparticles and detected by an immunospecific rabbit antihuman sIL-2R-alkaline phosphatase conjugate. A distinct advantage of the technique was rapid turn-around time: 1-24 results were obtained in less than 50 min. Cyclosporine trough concentrations were determined by radioimmunoassay or high-performance liquid chromatography. Diagnosis of rejection was established by clinical and histological criteria. The mean sIL-2R concentration in patients receiving antilymphocyte antibody induction therapy increased from 3486 +/- 1729 U/ml (+/- SD) at the time of transplant to a maximum of 7395 +/- 7101 U/ml on the third day posttransplant; this increase was not observed in patients receiving triple therapy (P less than 0.0001). By the sixth day of posttransplant, there were no differences in sIL-2R levels in the two groups. Fifty rejection episodes were observed in 29 patients on triple therapy. The mean sIL-2R concentration rose from 3022 U/ml at the data point prior to rejection to 3524 U/ml at the time of rejection. Thirty-four rejection episodes were observed in 26 patients receiving induction therapy. The mean sIL-2R concentration was 3015 U/ml at the data point prior to rejection and 4815 U/ml at the time of rejection. The sIL-2R concentrations began increasing earlier and rose higher in rejecting patients who received induction therapy than in those receiving triple therapy. Early posttransplant sIL-2R levels increased significantly more in cadaver recipients than in LRD recipients, reaching a maximum on day 2 posttransplant (P less than 0.001). Prerejection sIL-2R concentrations were significantly lower in LRD recipients than in cadaver recipients (2248 U/ml vs. 4290 U/ml, P less than 0.02), as were sIL-2R levels at the time of diagnosis of rejection (2800 U/ml vs. 4832 U/ml, P = 0.01). The mean sIL-2R level in stable long-term graft recipients was 2110 U/ml, with approximately 90% of values less than 3000 U/ml.(ABSTRACT TRUNCATED AT 400 WORDS)

Prevention and control of infection

Foal septicemia is a major cause of neonatal morbidity and mortality. In order to improve success rates, earlier diagnosis and treatment are essential. This article stresses methods to prevent and treat infections in the compromised equine neonate.