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Hojat LS, Wilson BM, Satlin MJ, Perez F, Mojica MF, Singer ME, Bonomo RA, Epstein LH. 14-Year Epidemiologic study of Pseudomonas aeruginosa bloodstream infection incidence and resistance in the Veterans Health Administration system, 2009-2022. JAC Antimicrob Resist 2024; 6:dlae031. [PMID: 38449517 PMCID: PMC10914452 DOI: 10.1093/jacamr/dlae031] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 02/12/2024] [Indexed: 03/08/2024] Open
Abstract
Background Multidrug resistant Pseudomonas aeruginosa (PA) represents a serious threat to hospitalized patients. Characterizing the incidence of PA infection and degree of resistance can inform empiric treatment and preventative measures. Objectives We sought to describe trends in incidence and resistance characteristics of PA bloodstream infections (BSI) observed within the Veterans Health Administration (VHA) system and identify factors contributing to higher observed mortality within this population. Methods We characterized demographic and clinical features of unique patients among the VHA population presenting with their first episode of PA-BSI between 2009 and 2022 and summarized trends related to mortality and resistance phenotype based on year and geographical location. We additionally used logistic regression analysis to identify predictors of 30-day mortality among this cohort. Results We identified 8039 PA-BSIs during the study period, 32.7% of which were hospital onset. Annual PA-BSI cases decreased by 35.8%, and resistance among all antimicrobial classes decreased during the study period, while the proportion of patients receiving early active treatment based on susceptibility testing results increased. Average 30-day mortality rate was 23.3%. Higher Charlson Comorbidity Index, higher mAPACHE score, VHA facility complexity 1b and hospital-onset cases were associated with higher mortality, and early active treatment was associated with lower mortality. Conclusions PA-BSI resistance decreased across the VHA system during the study period. Further investigation of antimicrobial stewardship measures possibly contributing to the observed decreased resistance in this cohort and identification of measures to improve on the high mortality associated with PA-BSI in the VHA population is warranted.
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Affiliation(s)
- Leila S Hojat
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, Case Western Reserve University, 11100 Euclid Avenue, 44106, Cleveland, OH, USA
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Brigid M Wilson
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, Case Western Reserve University, 11100 Euclid Avenue, 44106, Cleveland, OH, USA
- Geriatric Research Education and Clinical Center (GRECC), The VA Northeast Ohio Healthcare System, Cleveland, OH, USA
| | - Michael J Satlin
- Division of Infectious Diseases, Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Federico Perez
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, Case Western Reserve University, 11100 Euclid Avenue, 44106, Cleveland, OH, USA
- Geriatric Research Education and Clinical Center (GRECC), The VA Northeast Ohio Healthcare System, Cleveland, OH, USA
- Cleveland VAMC Center for Antimicrobial Resistance and Epidemiology (Case VA CARES), Case Western Reserve University, Cleveland, OH, USA
| | - Maria F Mojica
- Research Service, VA Northeast Ohio Healthcare System, Cleveland, OH, USA
- Grupo de Resistencia Antimicrobiana y Epidemiología Hospitalaria, Universidad El Bosque, Bogotá, Colombia
| | - Mendel E Singer
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, USA
| | - Robert A Bonomo
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, Case Western Reserve University, 11100 Euclid Avenue, 44106, Cleveland, OH, USA
- Geriatric Research Education and Clinical Center (GRECC), The VA Northeast Ohio Healthcare System, Cleveland, OH, USA
- Cleveland VAMC Center for Antimicrobial Resistance and Epidemiology (Case VA CARES), Case Western Reserve University, Cleveland, OH, USA
- Research Service, VA Northeast Ohio Healthcare System, Cleveland, OH, USA
| | - Lauren H Epstein
- US Department of Veterans Affairs Medical Center, Emory University, Atlanta, Georgia, USA
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Abul Y, Nugent C, Vishnepolskiy I, Wallace T, Dickerson E, Holland L, Esparza I, Winkis M, Wali KT, Chan PA, Baier RR, Recker A, Kaczynski M, Kamojjala S, Pralea A, Rice H, Osias O, Oyebanji OA, Olagunju O, Cao Y, Li CJ, Roederer A, Pfeifer WM, King CL, Bosch J, Nanda A, McNicoll L, Mujahid N, Raza S, Tyagi R, Wilson BM, White EM, Canaday DH, Gravenstein S, Balazs AB. Broad immunogenicity to prior SARS-CoV-2 strains and JN.1 variant elicited by XBB.1.5 vaccination in nursing home residents. medRxiv 2024:2024.03.21.24303684. [PMID: 38585784 PMCID: PMC10996740 DOI: 10.1101/2024.03.21.24303684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
Background SARS-CoV-2 vaccination has reduced hospitalization and mortality for nursing home residents (NHRs). However, emerging variants coupled with waning immunity, immunosenescence, and variability of vaccine efficacy undermine vaccine effectiveness. We therefore need to update our understanding of the immunogenicity of the most recent XBB.1.5 monovalent vaccine to variant strains among NHRs. Methods The current study focuses on a subset of participants from a longitudinal study of consented NHRs and HCWs who have received serial blood draws to assess immunogenicity with each SARS-CoV-2 mRNA vaccine dose. We report data on participants who received the XBB.1.5 monovalent vaccine after FDA approval in Fall 2023. NHRs were classified based on whether they had an interval SARS-CoV-2 infection between their first bivalent vaccine dose and their XBB.1.5 monovalent vaccination. Results The sample included 61 NHRs [median age 76 (IQR 68-86), 51% female] and 28 HCWs [median age 45 (IQR 31-58), 46% female). Following XBB.1.5 monovalent vaccination, there was a robust geometric mean fold rise (GMFR) in XBB.1.5-specific neutralizing antibody titers of 17.3 (95% confidence interval [CI] 9.3, 32.4) and 11.3 (95% CI 5, 25.4) in NHRs with and without interval infection, respectively. The GMFR in HCWs was 13.6 (95% CI 8.4,22). Similarly, we noted a robust GMFR in JN.1-specific neutralizing antibody titers of 14.9 (95% CI 7.9, 28) and 6.5 (95% CI 3.3, 13.1) among NHRs with and without interval infection, and a GMFR of 11.4 (95% CI 6.2, 20.9) in HCWs. NHRs with interval SARS-CoV-2 infection had higher neutralizing antibody titers across all analyzed strains following XBB.1.5 monovalent vaccination, compared to NHRs without interval infection. Conclusion The XBB.1.5 monovalent vaccine significantly elevates Omicron-specific neutralizing antibody titers to XBB.1.5 and JN.1 strains in both NHRs and HCWs. This response was more pronounced in individuals known to be infected with SARS-CoV-2 since bivalent vaccination. Impact Statement All authors certify that this work entitled " Broad immunogenicity to prior strains and JN.1 variant elicited by XBB.1.5 vaccination in nursing home residents " is novel. It shows that the XBB.1.5 monovalent vaccine significantly elevates Omicron-specific neutralizing antibody titers in both nursing home residents and healthcare workers to XBB and BA.28.6/JN.1 strains. This work is important since JN.1 increased from less than 0.1% to 94% of COVID-19 cases from October 2023 to February 2024 in the US. This information is timely given the CDC's latest recommendation that adults age 65 and older receive a Spring 2024 XBB booster. Since the XBB.1.5 monovalent vaccine produces compelling immunogenicity to the most prevalent circulating JN.1 strain in nursing home residents, our findings add important support and rationale to encourage vaccine uptake. Key Points Emerging SARS-CoV-2 variants together with waning immunity, immunosenescence, and variable vaccine efficacy reduce SARS-CoV-2 vaccine effectiveness in nursing home residents.XBB.1.5 monovalent vaccination elicited robust response in both XBB.1.5 and JN.1 neutralizing antibodies in nursing home residents and healthcare workers, although the absolute titers to JN.1 were less than titers to XBB.1.5Why does this paper matter? Among nursing home residents, the XBB.1.5 monovalent SARS-CoV-2 vaccine produces compelling immunogenicity to the JN.1 strain, which represents 94% of all COVID-19 cases in the U.S. as of February 2024.
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Bej TA, Wilson BM, El Chakhtoura N, Perez F, Jump RLP. Change in Provider Specialty Was Associated With Less Fluoroquinolone Use at a Veterans Affairs Long-Term Care Setting. J Am Med Dir Assoc 2024:104927. [PMID: 38320741 DOI: 10.1016/j.jamda.2023.12.015] [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] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 12/23/2023] [Indexed: 02/17/2024]
Abstract
OBJECTIVE In July 2021, as part of a planned multiyear broad and long-term organizational realignment, the general medicine service assumed continuous care of residents at a Community Living Center (CLC), which are nursing homes within the Veterans Affairs (VA) health care system. We hypothesized that practitioners accustomed to caring for patients in acute care would be more likely to prescribe antibiotics to long-term care residents. DESIGN Retrospective cohort study. SETTINGS AND PARTICIPANTS Residents of a 105-bed CLC associated with a large VA medical center. METHODS Our cohort included CLC residents between July 1, 2020, and June 30, 2022. We used administrative data to assess resident demographics and medical conditions in the 1 year before and after the change of practitioners. We also compared antibiotics agents prescribed and the following antibiotic use metrics in the year before and after the change: days of therapy (DOT) per 1000 bed days of care (BDOC), antibiotic starts/1000 BDOC, and mean length of therapy in days. RESULTS Resident characteristics and overall antibiotic use metrics were similar before and after the change in staffing. The specific agents prescribed differed, with a decrease in fluoroquinolones (14.3 to 5.8 DOT/1000 BDOC; P < .01) and an increase doxycycline (7.4 vs 19.1 DOT/1000 BDOC; P < .01) after the staff change. Rates of Clostridioides difficile infection also decreased, from 6.23 to 3.41 cases/10,000 BDOC after the change in staffing. CONCLUSIONS AND IMPLICATIONS The comparable antibiotic use metrics before and after the general medical service assumed care of the CLC residents may be explained by constancy in resident population and other facility-related factors. Differences in the types of agents used suggests that antibiotic stewardship efforts can be tailored not only to the setting and patient population but also to the practitioners' discipline.
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Affiliation(s)
- Taissa A Bej
- Geriatric Research Education and Clinical Center (GRECC), VA Northeast Ohio Healthcare System, Cleveland, OH, USA
| | - Brigid M Wilson
- Geriatric Research Education and Clinical Center (GRECC), VA Northeast Ohio Healthcare System, Cleveland, OH, USA; Division of Infectious Diseases & HIV Medicine in the Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Nadim El Chakhtoura
- Division of Infectious Diseases & HIV Medicine in the Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA; Medical Service, VA Northeast Ohio Healthcare System, Cleveland, OH, USA
| | - Federico Perez
- Geriatric Research Education and Clinical Center (GRECC), VA Northeast Ohio Healthcare System, Cleveland, OH, USA; Division of Infectious Diseases & HIV Medicine in the Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Robin L P Jump
- TECH-GRECC, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA; Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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Pearlmutter BS, Carlisle MG, Wilson BM, Sangwan N, Donskey CJ. Pulsed dosing and extended daily dosing of oral vancomycin do not facilitate clearance of Clostridioides difficile colonization in mice. Antimicrob Agents Chemother 2024; 68:e0090323. [PMID: 38095427 PMCID: PMC10777828 DOI: 10.1128/aac.00903-23] [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: 07/07/2023] [Accepted: 09/27/2023] [Indexed: 01/11/2024] Open
Abstract
Vancomycin taper and pulse regimens are commonly used to treat recurrent Clostridioides difficile infections, but the mechanism by which these regimens might reduce recurrences is unclear. Here, we used a mouse model to test the hypothesis that pulse dosing of vancomycin after a 10-day treatment course enhances clearance of C. difficile from the intestinal tract. Mice with C. difficile colonization received 10 days of once-daily oral vancomycin followed by 20 days of treatment with saline (controls), daily vancomycin, or pulse dosing of vancomycin every 2 or 3 days. Stool samples were collected to measure the concentration of C. difficile during and after treatment, vancomycin concentrations, and growth of vegetative C. difficile during every 3 days dosing. Pulse dosing of vancomycin was not effective in maintaining suppression of C. difficile (P > 0.05 in comparison to saline controls); growth of vegetative C. difficile occurred between pulse doses when vancomycin decreased to undetectable levels. Daily dosing of vancomycin suppressed C. difficile during treatment, but recurrent colonization occurred after treatment in more than 75% of mice, and by post-treatment day 14, there was no significant difference among the control, pulse dosing, and daily dosing groups (P > 0.05). These findings demonstrate that pulse dosing of vancomycin every 2 or 3 days does not facilitate the clearance of C. difficile spores in mice. Studies are needed to examine the impact of vancomycin taper and pulsed regimens in patients.
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Affiliation(s)
- Basya S. Pearlmutter
- Research Service, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio, USA
| | - Matthew G. Carlisle
- Geriatric Research Education and Clinical Center, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio, USA
| | - Brigid M. Wilson
- Geriatric Research Education and Clinical Center, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio, USA
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Naseer Sangwan
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Lerner Research Institute/Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Curtis J. Donskey
- Geriatric Research Education and Clinical Center, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio, USA
- Lerner Research Institute/Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
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Hojat LS, Wilson BM, Perez F, Mojica MF, Singer ME, Bonomo RA, Epstein LH. Association of COVID-19 coinfection with increased mortality among patients with Pseudomonas aeruginosa bloodstream infection in the Veterans Health Administration system. Antimicrob Steward Healthc Epidemiol 2023; 3:e237. [PMID: 38156202 PMCID: PMC10753479 DOI: 10.1017/ash.2023.455] [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] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 08/14/2023] [Accepted: 08/17/2023] [Indexed: 12/30/2023]
Abstract
Objective Pseudomonas aeruginosa bloodstream infection (PA-BSI) and COVID-19 are independently associated with high mortality. We sought to demonstrate the impact of COVID-19 coinfection on patients with PA-BSI. Design Retrospective cohort study. Setting Veterans Health Administration. Patients Hospitalized patients with PA-BSI in pre-COVID-19 (January 2009 to December 2019) and COVID-19 (January 2020 to June 2022) periods. Patients in the COVID-19 period were further stratified by the presence or absence of concomitant COVID-19 infection. Methods We characterized trends in resistance, treatment, and mortality over the study period. Multivariable logistic regression and modified Poisson analyses were used to determine the association between COVID-19 and mortality among patients with PA-BSI. Additional predictors included demographics, comorbidities, disease severity, antimicrobial susceptibility, and treatment. Results A total of 6,714 patients with PA-BSI were identified. Throughout the study period, PA resistance rates decreased. Mortality decreased during the pre-COVID-19 period and increased during the COVID-19 period. Mortality was not significantly different between pre-COVID-19 (24.5%, 95% confidence interval [CI] 23.3-28.6) and COVID-19 period/COVID-negative (26.0%, 95% CI 23.5-28.6) patients, but it was significantly higher in COVID-19 period/COVID-positive patients (47.2%, 35.3-59.3). In the modified Poisson analysis, COVID-19 coinfection was associated with higher mortality (relative risk 1.44, 95% CI 1.01-2.06). Higher Charlson Comorbidity Index, higher modified Acute Physiology and Chronic Health Evaluation score, and no targeted PA-BSI treatment within 48 h were also predictors of higher mortality. Conclusions Higher mortality was observed in patients with COVID-19 coinfection among patients with PA-BSI. Future studies should explore this relationship in other settings and investigate potential SARS-CoV-2 and PA synergy.
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Affiliation(s)
- Leila S. Hojat
- Department of Medicine, Division of Infectious Diseases, Case Western Reserve University, Cleveland, OH, USA
- Division of Infectious Diseases and HIV Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Brigid M. Wilson
- Department of Medicine, Division of Infectious Diseases, Case Western Reserve University, Cleveland, OH, USA
- Geriatric Research Education and Clinical Center (GRECC), the VA Northeast Ohio Healthcare System, Cleveland, OH, USA
| | - Federico Perez
- Department of Medicine, Division of Infectious Diseases, Case Western Reserve University, Cleveland, OH, USA
- Geriatric Research Education and Clinical Center (GRECC), the VA Northeast Ohio Healthcare System, Cleveland, OH, USA
- Case Western Reserve University, Cleveland VAMC Center for Antimicrobial Resistance and Epidemiology (Case VA CARES), Cleveland, OH, USA
| | - Maria F. Mojica
- Case Western Reserve University, Cleveland VAMC Center for Antimicrobial Resistance and Epidemiology (Case VA CARES), Cleveland, OH, USA
- Research Service, VA Northeast Ohio Healthcare System, Cleveland, OH, USA
- Grupo de Resistencia Antimicrobiana y Epidemiología Hospitalaria, Universidad El Bosque, Bogotá, Colombia
- Departments of Pathology, Pharmacology, Molecular Biology and Microbiology, Biochemistry, and Proteomics and Bioinformatics, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Mendel E. Singer
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, USA
| | - Robert A. Bonomo
- Department of Medicine, Division of Infectious Diseases, Case Western Reserve University, Cleveland, OH, USA
- Geriatric Research Education and Clinical Center (GRECC), the VA Northeast Ohio Healthcare System, Cleveland, OH, USA
- Case Western Reserve University, Cleveland VAMC Center for Antimicrobial Resistance and Epidemiology (Case VA CARES), Cleveland, OH, USA
- Research Service, VA Northeast Ohio Healthcare System, Cleveland, OH, USA
- Departments of Pathology, Pharmacology, Molecular Biology and Microbiology, Biochemistry, and Proteomics and Bioinformatics, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Lauren H. Epstein
- Infectious Diseases, US Department of Veterans Affairs Medical Center, Decatur, GA, USA
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Oyebanji OA, Abul Y, Wilson BM, Bosch J, Didion EM, Paxitzis AN, Sundheimer N, Ragavapuram V, Wilk D, Keresztesy D, Aung H, Cao Y, King CL, Balazs AB, White EM, Gravenstein S, Canaday DH. Neutralization and binding antibody response to second bivalent COVID-19 vaccination in nursing home residents. J Am Geriatr Soc 2023; 71:3947-3950. [PMID: 37589423 PMCID: PMC10840677 DOI: 10.1111/jgs.18557] [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] [Received: 07/18/2023] [Accepted: 07/20/2023] [Indexed: 08/18/2023]
Affiliation(s)
| | - Yasin Abul
- Center of Innovation in Long-Term Services and Supports, Veterans Administration Medical Center, Providence, RI
- Division of Geriatrics and Palliative Medicine, Alpert Medical School of Brown University, Providence, RI
| | - Brigid M. Wilson
- Geriatric Research Education and Clinical Center, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, OH
| | | | | | | | | | | | | | | | | | | | | | | | | | - Stefan Gravenstein
- Center of Innovation in Long-Term Services and Supports, Veterans Administration Medical Center, Providence, RI
- Division of Geriatrics and Palliative Medicine, Alpert Medical School of Brown University, Providence, RI
- Brown University School of Public Health Center for Gerontology and Healthcare Research, Providence, RI
| | - David H. Canaday
- Geriatric Research Education and Clinical Center, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, OH
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Taylor LN, Wilson BM, Singh M, Irvine J, Jolles SA, Kowal C, Bej TA, Crnich CJ, Jump RLP. Syndromic Antibiograms and Nursing Home Clinicians' Antibiotic Choices for Urinary Tract Infections. JAMA Netw Open 2023; 6:e2349544. [PMID: 38150250 PMCID: PMC10753399 DOI: 10.1001/jamanetworkopen.2023.49544] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 11/12/2023] [Indexed: 12/28/2023] Open
Abstract
Importance Empirical antibiotic prescribing in nursing homes (NHs) is often suboptimal. The potential for antibiograms to improve empirical antibiotic decision-making in NHs remains poorly understood. Objective To determine whether providing NH clinicians with a urinary antibiogram improves empirical antibiotic treatment of urinary tract infections (UTIs). Design, Setting, and Participants This was a survey study using clinical vignettes. Participants were recruited via convenience sampling of professional organization listservs of NH clinicians practicing in the US from December 2021 through April 2022. Data were analyzed from July 2022 to June 2023. Interventions Respondents were randomized to complete vignettes using a traditional antibiogram (TA), a weighted-incidence syndromic combination antibiogram (WISCA), or no tool. Participants randomized to antibiogram groups were asked to use the antibiogram to empirically prescribe an antibiotic. Participants randomized to the no tool group functioned as controls. Main Outcomes and Measures Empirical antibiotic selections were characterized as microbiologically (1) active and (2) optimal according to route of administration and spectrum of activity. Results Of 317 responses, 298 (95%) were included in the analysis. Duplicate responses (15 participants), location outside the US (2 participants), and uninterpretable responses (2 participants) were excluded. Most respondents were physicians (217 respondents [73%]) and had over 10 years of NH practice experience (155 respondents [52%]). A mixed-effects logistic model found that use of the TA (odds ratio [OR], 1.41; 95% CI, 1.19-1.68; P < .001) and WISCA (OR, 1.54; 95% CI, 1.30-1.84; P < .001) were statistically superior to no tool when choosing an active empirical antibiotic. A similarly constructed model found that use of the TA (OR, 1.94; 95% CI, 1.42-2.66; P < .001) and WISCA (OR, 1.7; 95% CI, 1.24-2.33; P = .003) were statistically superior to no tool when selecting an optimal empirical antibiotic. Although there were differences between tools within specific vignettes, when compared across all vignettes, the TA and WISCA performed similarly for active (OR, 1.09; 95% CI, 0.92-1.30; P = .59) and optimal (OR, 0.87; 95% CI, 0.64-1.20; P = .69) antibiotics. Conclusions and Relevance Providing NH clinicians with a urinary antibiogram was associated with selection of active and optimal antibiotics when empirically treating UTIs under simulated conditions. Although the antibiogram format was not associated with decision-making in aggregate, context-specific effects may have been present, supporting further study of syndromic antibiograms in clinical practice.
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Affiliation(s)
- Lindsay N. Taylor
- University of Wisconsin School of Medicine and Public Health, Madison
- William S. Middleton Veterans Affairs Medical Center, Madison
- University of Wisconsin Hospital and Clinics, Madison
| | - Brigid M. Wilson
- Geriatric Research Education and Clinical Center (GRECC), Veterans Affairs Northeast Ohio Healthcare System, Cleveland
- Division of Infectious Diseases and HIV Medicine in the Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Mriganka Singh
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Warren Alpert School of Medicine at Brown University, Providence, Rhode Island
| | - Jessica Irvine
- University of Wisconsin School of Medicine and Public Health, Madison
| | - Sally A. Jolles
- University of Wisconsin School of Medicine and Public Health, Madison
| | | | - Taissa A. Bej
- Geriatric Research Education and Clinical Center (GRECC), Veterans Affairs Northeast Ohio Healthcare System, Cleveland
- Division of Infectious Diseases and HIV Medicine in the Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Christopher J. Crnich
- University of Wisconsin School of Medicine and Public Health, Madison
- William S. Middleton Veterans Affairs Medical Center, Madison
- University of Wisconsin Hospital and Clinics, Madison
| | - Robin L. P. Jump
- TECH-GRECC, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of Geriatric Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Greentree DH, Wilson BM, Donskey CJ. Carbon Dioxide Monitoring Demonstrates Variations in the Quality of Ventilation on Public Transportation Buses and University Student Shuttle Vans and Identifies Effective Interventions. Pathog Immun 2023; 8:148-160. [PMID: 38035133 PMCID: PMC10686372 DOI: 10.20411/pai.v8i1.619] [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: 09/03/2023] [Accepted: 10/13/2023] [Indexed: 12/02/2023] Open
Abstract
Background There is a risk for transmission of severe acute respiratory syndrome 2 (SARS-CoV-2) and other respiratory viruses in motor vehicles, particularly if ventilation is inadequate. Methods We used carbon dioxide monitoring to examine the quality of ventilation in several public transportation buses and in university student shuttle vans in the Cleveland metro area during peak and non-peak travel times. Carbon dioxide levels above 800 parts per million (ppm) were considered an indicator of suboptimal ventilation for the number of people present. In the shuttle vans, we evaluated the impact of an intervention to improve ventilation. Results In large articulated buses with 2 ventilation systems, carbon dioxide concentrations never exceeded 800 ppm, whereas in standard buses with 1 ventilation system concentrations rose above 800 ppm during peak travel times and on some trips during non-peak travel times. In shuttle vans, the ventilation system was not turned on during routine operation, and carbon dioxide levels rose above 800 ppm on all trips during peak and non-peak travel times. In the shuttle vans, an intervention involving operation of the existing ventilation system resulted in a significant reduction in carbon dioxide levels (mean concentration, 1,042 no intervention versus 785 with intervention; P < 0.001). Conclusions Our findings demonstrate substantial variability in the quality of ventilation in public transportation buses and university shuttle vans. There is a need for efforts to assess and optimize ventilation in motor vehicles used for public transportation to reduce the risk for aerosol-mediated transmission of respiratory viruses. Carbon dioxide monitoring may provide a useful tool to assess and improve ventilation.
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Affiliation(s)
- David Henry Greentree
- Department of Biology, College of Arts and Sciences, Case Western Reserve University, Cleveland, Ohio
- College of Medicine, The Ohio State University, Columbus, Ohio
| | - Brigid M. Wilson
- Geriatric Research, Education and Clinical Center, Louis Stokes Veterans Affairs Medical Center, Cleveland, Ohio
- School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Curtis J. Donskey
- Geriatric Research, Education and Clinical Center, Louis Stokes Veterans Affairs Medical Center, Cleveland, Ohio
- School of Medicine, Case Western Reserve University, Cleveland, Ohio
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Smith CL, Bednarchik B, Aung H, Wilk DJ, Boxer RS, Daddato AE, Wilson BM, Gravenstein S, Canaday DH. Humoral and Cellular Immunity Induced by Adjuvanted and Standard Trivalent Influenza Vaccine in Older Nursing Home Residents. J Infect Dis 2023; 228:704-714. [PMID: 36951196 DOI: 10.1093/infdis/jiad071] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 03/07/2023] [Accepted: 03/21/2023] [Indexed: 03/24/2023] Open
Abstract
BACKGROUND Despite wide use of adjuvanted influenza vaccine in nursing home residents (NHR), little immunogenicity data exist for this population. METHODS We collected blood from NHR (n = 85) living in nursing homes participating in a cluster randomized clinical trial comparing MF59-adjuvanted trivalent inactivated influenza vaccine (aTIV) with nonadjuvanted vaccine (TIV) (parent trial, NCT02882100). NHR received either vaccine during the 2016-2017 influenza season. We assessed cellular and humoral immunity using flow cytometry and hemagglutinin inhibition, antineuraminidase (enzyme-linked lectin assay), and microneutralization assays. RESULTS Both vaccines were similarly immunogenic and induced antigen-specific antibodies and T cells, but aTIV specifically induced significantly larger 28 days after vaccination (D28) titers against A/H3N2 neuraminidase than TIV. CONCLUSIONS NHRs respond immunologically to TIV and aTIV. From these data, the larger aTIV-induced antineuraminidase response at D28 may help explain the increased clinical protection observed in the parent clinical trial for aTIV over TIV in NHR during the A/H3N2-dominant 2016-2017 influenza season. Additionally, a decline back to prevaccination titers at 6 months after vaccination emphasizes the importance of annual vaccination against influenza. CLINICAL TRIALS REGISTRATION NCT02882100.
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Affiliation(s)
- Carson L Smith
- Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Beth Bednarchik
- Department of Medicine, University Hospitals Case Medical Center, Cleveland, OH, USA
| | - Htin Aung
- Division of Infectious Diseases & HIV Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Dennis J Wilk
- Division of Infectious Diseases & HIV Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Rebecca S Boxer
- Institute for Health Research, Kaiser Permanente of Colorado, Aurora, CO, USA
| | - Andrea E Daddato
- Institute for Health Research, Kaiser Permanente of Colorado, Aurora, CO, USA
| | - Brigid M Wilson
- Geriatric Research, Education and Clinical Center, Louis Stokes Veterans Affairs Northeast Ohio Healthcare System, Cleveland, OH, USA
- Division of Infectious Diseases and HIV Medicine, Case Western Reserve School of Medicine, Cleveland, OH, USA
| | - Stefan Gravenstein
- Division of Geriatrics and Palliative Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
- Center on Innovation in Long-Term Services and Supports, Providence Veterans Administration Medical Center, Providence, RI, USA
| | - David H Canaday
- Division of Infectious Diseases & HIV Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
- Geriatric Research, Education and Clinical Center, Louis Stokes Veterans Affairs Northeast Ohio Healthcare System, Cleveland, OH, USA
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10
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Jump RLP, Mongilardi N, Wilson BM, Bej TA, Song S, Kowal CM, Perez F, Akpoji UC. Low rates of antibiotics prescribed during telehealth primary-care visits persisted during the coronavirus disease 2019 (COVID-19) pandemic. Infect Control Hosp Epidemiol 2023; 44:1518-1521. [PMID: 36762817 DOI: 10.1017/ice.2022.309] [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] [Indexed: 02/11/2023]
Abstract
For primary care clinics at a Veterans' Affairs (VA) medical center, the shift from in-person to telehealth visits during the coronavirus disease 2019 (COVID-19) pandemic was associated with low rates of antibiotic prescription. Understanding contextual factors associated with antibiotic prescription practices during telehealth visits may help promote antibiotic stewardship in primary care settings.
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Affiliation(s)
- Robin L P Jump
- Geriatric Research Education and Clinical Center (GRECC), Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of Geriatrics, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Nicole Mongilardi
- GRECC, VA Northeast Ohio Healthcare System, Cleveland, Ohio
- Division of Infectious Diseases & HIV Medicine in the Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Brigid M Wilson
- GRECC, VA Northeast Ohio Healthcare System, Cleveland, Ohio
- Division of Infectious Diseases & HIV Medicine in the Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Taissa A Bej
- GRECC, VA Northeast Ohio Healthcare System, Cleveland, Ohio
| | - Sunah Song
- Cleveland Institute for Computational Biology, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | | | - Federico Perez
- GRECC, VA Northeast Ohio Healthcare System, Cleveland, Ohio
- Division of Infectious Diseases & HIV Medicine in the Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Ukwen C Akpoji
- Department of Pharmacy, VA Northeast Ohio Healthcare System, Cleveland, Ohio (Present affiliation: Division of Infectious Diseases and Global Medicine, Department of Medicine, University of Florida College of Medicine, Gainesville, Florida [N.M.])]
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11
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Shive CL, Kowal CM, Desotelle AF, Nguyen Y, Carbone S, Kostadinova L, Davitkov P, O’Mara M, Reihs A, Siddiqui H, Wilson BM, Anthony DD. Endotoxemia Associated with Liver Disease Correlates with Systemic Inflammation and T Cell Exhaustion in Hepatitis C Virus Infection. Cells 2023; 12:2034. [PMID: 37626844 PMCID: PMC10453378 DOI: 10.3390/cells12162034] [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: 06/16/2023] [Revised: 07/29/2023] [Accepted: 08/04/2023] [Indexed: 08/27/2023] Open
Abstract
Both acute and chronic hepatitis C virus (HCV) infections are characterized by inflammation. HCV and reduced liver blood filtration contribute to inflammation; however, the mechanisms of systemic immune activation and dysfunction as a result of HCV infection are not clear. We measured circulating inflammatory mediators (IL-6, IP10, sCD163, sCD14), indices of endotoxemia (EndoCab, LBP, FABP), and T cell markers of exhaustion and senescence (PD-1, TIGIT, CD57, KLRG-1) in HCV-infected participants, and followed a small cohort after direct-acting anti-viral therapy. IL-6, IP10, Endocab, LBP, and FABP were elevated in HCV participants, as were T cell co-expression of exhaustion and senescence markers. We found positive associations between IL-6, IP10, EndoCab, LBP, and co-expression of T cell markers of exhaustion and senescence. We also found numerous associations between reduced liver function, as measured by plasma albumin levels, and T cell exhaustion/senescence, inflammation, and endotoxemia. We found positive associations between liver stiffness (TE score) and plasma levels of IL-6, IP10, and LBP. Lastly, plasma IP10 and the proportion of CD8 T cells co-expressing PD-1 and CD57 decreased after initiation of direct-acting anti-viral therapy. Although associations do not prove causality, our results support the model that translocation of microbial products, resulting from decreased liver blood filtration, during HCV infection drives chronic inflammation that results in T cell exhaustion/senescence and contributes to systemic immune dysfunction.
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Affiliation(s)
- Carey L. Shive
- Cleveland VA Medical Center, Cleveland, OH 44106, USA; (C.M.K.); (A.F.D.); (Y.N.); (S.C.); (L.K.); (P.D.); (M.O.); (A.R.); (H.S.); (B.M.W.); (D.D.A.)
- Pathology Department, School of Medicine, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Corinne M. Kowal
- Cleveland VA Medical Center, Cleveland, OH 44106, USA; (C.M.K.); (A.F.D.); (Y.N.); (S.C.); (L.K.); (P.D.); (M.O.); (A.R.); (H.S.); (B.M.W.); (D.D.A.)
| | - Alexandra F. Desotelle
- Cleveland VA Medical Center, Cleveland, OH 44106, USA; (C.M.K.); (A.F.D.); (Y.N.); (S.C.); (L.K.); (P.D.); (M.O.); (A.R.); (H.S.); (B.M.W.); (D.D.A.)
| | - Ynez Nguyen
- Cleveland VA Medical Center, Cleveland, OH 44106, USA; (C.M.K.); (A.F.D.); (Y.N.); (S.C.); (L.K.); (P.D.); (M.O.); (A.R.); (H.S.); (B.M.W.); (D.D.A.)
| | - Sarah Carbone
- Cleveland VA Medical Center, Cleveland, OH 44106, USA; (C.M.K.); (A.F.D.); (Y.N.); (S.C.); (L.K.); (P.D.); (M.O.); (A.R.); (H.S.); (B.M.W.); (D.D.A.)
| | - Lenche Kostadinova
- Cleveland VA Medical Center, Cleveland, OH 44106, USA; (C.M.K.); (A.F.D.); (Y.N.); (S.C.); (L.K.); (P.D.); (M.O.); (A.R.); (H.S.); (B.M.W.); (D.D.A.)
| | - Perica Davitkov
- Cleveland VA Medical Center, Cleveland, OH 44106, USA; (C.M.K.); (A.F.D.); (Y.N.); (S.C.); (L.K.); (P.D.); (M.O.); (A.R.); (H.S.); (B.M.W.); (D.D.A.)
| | - Megan O’Mara
- Cleveland VA Medical Center, Cleveland, OH 44106, USA; (C.M.K.); (A.F.D.); (Y.N.); (S.C.); (L.K.); (P.D.); (M.O.); (A.R.); (H.S.); (B.M.W.); (D.D.A.)
| | - Alexandra Reihs
- Cleveland VA Medical Center, Cleveland, OH 44106, USA; (C.M.K.); (A.F.D.); (Y.N.); (S.C.); (L.K.); (P.D.); (M.O.); (A.R.); (H.S.); (B.M.W.); (D.D.A.)
| | - Hinnah Siddiqui
- Cleveland VA Medical Center, Cleveland, OH 44106, USA; (C.M.K.); (A.F.D.); (Y.N.); (S.C.); (L.K.); (P.D.); (M.O.); (A.R.); (H.S.); (B.M.W.); (D.D.A.)
| | - Brigid M. Wilson
- Cleveland VA Medical Center, Cleveland, OH 44106, USA; (C.M.K.); (A.F.D.); (Y.N.); (S.C.); (L.K.); (P.D.); (M.O.); (A.R.); (H.S.); (B.M.W.); (D.D.A.)
- Department of Medicine, School of Medicine, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Donald D. Anthony
- Cleveland VA Medical Center, Cleveland, OH 44106, USA; (C.M.K.); (A.F.D.); (Y.N.); (S.C.); (L.K.); (P.D.); (M.O.); (A.R.); (H.S.); (B.M.W.); (D.D.A.)
- Department of Medicine, School of Medicine, Case Western Reserve University, Cleveland, OH 44106, USA
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12
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Torres-Teran MM, Bennett CTP, Osborne AO, Cadnum JL, Wilson BM, Donskey CJ. Effectiveness of ultraviolet-C light treatment of shoes in reducing the transfer of pathogens into patient rooms by shoes of healthcare personnel. Infect Control Hosp Epidemiol 2023; 44:1361-1364. [PMID: 36177872 DOI: 10.1017/ice.2022.242] [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] [Indexed: 11/06/2022]
Abstract
Contaminated shoes are a potential vector for dissemination of healthcare-associated pathogens. We demonstrated that healthcare personnel walking into patient rooms frequently transferred pathogens from their shoes to the floor. An 8-second treatment of shoes with a UV-C decontamination device significantly reduced the frequency of transfer of vegetative bacterial pathogens.
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Affiliation(s)
| | | | - Andrew O Osborne
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Jennifer L Cadnum
- Research Service, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio
| | - Brigid M Wilson
- Research Service, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio
| | - Curtis J Donskey
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Geriatric Research, Education, and Clinical Center, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio
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13
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Gravenstein S, DeVone F, Oyebanji OA, Abul Y, Cao Y, Chan PA, Halladay CW, McConeghy KW, Nugent C, Bosch J, King CL, Wilson BM, Balazs AB, White EM, Canaday DH. Durability of immunity and clinical protection in nursing home residents following bivalent SARS-CoV-2 vaccination. medRxiv 2023:2023.04.25.23289050. [PMID: 37163130 PMCID: PMC10168517 DOI: 10.1101/2023.04.25.23289050] [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] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Background Vaccines have substantially mitigated the disproportional impact of SARS-CoV-2 on the high morbidity and mortality experienced by nursing home residents. However, variation in vaccine efficacy, immune senescence and waning immunity all undermine vaccine effectiveness over time. The introduction of the bivalent vaccine in September 2022 aimed to counter this increasing susceptibility and consequences of breakthrough infection, however data on the durability and protection of the vaccine are limited. We evaluated the durability of immunity and protection after the first bivalent vaccination to SARS-CoV-2 in nursing home residents. Methods For the immunologic evaluation, community nursing home volunteers agreed to serial blood sampling before, at two weeks, three and six months after each vaccination for antibodies to spike protein and pseudovirus neutralization activity over time. Concurrent clinical outcomes were evaluated by reviewing electronic health record data from residents living in Veterans Administration managed nursing home units. Residents without recent infection but prior vaccination to SARS-CoV-2 were followed over time beginning with administration of the newly available bivalent vaccine using a target trial emulation (TTE) approach; TTE compared time to breakthrough infection, hospitalization and death between those who did and did not receive the bivalent vaccine. Results We evaluated antibodies in 650 nursing home residents; 452 had data available following a first monovalent booster, 257 following a second monovalent booster and 321 following a bivalent vaccine. We found a rise in BA.5 neutralization activity from the first and second monovalent boosters through the bivalent vaccination regardless of prior SARS-CoV-2 history. Titers declined at three and six months after the bivalent vaccination but generally exceeded those at three months compared to either prior boost. BA.5 neutralization titers six months after the bivalent vaccination were diminished but had detectable levels in 80% of infection-naive and 100% of prior infected individuals. TTE evaluated 5903 unique subjects, of whom 2235 received the bivalent boost. TTE demonstrated 39% or greater reduction in risk of infection, hospitalization or death at four months following the bivalent boost. Conclusion Immunologic results mirrored those of the TTE and suggest bivalent vaccination added substantial protection for up to six months after bivalent vaccination with notable exceptions. However, the level of protection declined over this period, and by six months may open a window of added vulnerability to infection before the next updated vaccine becomes available. We strongly agree with the CDC recommendation that those who have not received a bivalent vaccination receive that now and these results support a second bivalent booster for those at greatest risk which includes many nursing home residents.
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Affiliation(s)
- Stefan Gravenstein
- Warren Alpert Medical School, Brown University, Providence, RI
- Department of Health Services, Policy & Practice, School of Public Health, Brown University, Providence, Rhode Island
- Center of Innovation in Long-Term Services and Supports, Veterans Administration (VA) Medical Center, Providence, Rhode Island
| | - Frank DeVone
- Center of Innovation in Long-Term Services and Supports, Veterans Administration (VA) Medical Center, Providence, Rhode Island
| | | | - Yasin Abul
- Warren Alpert Medical School, Brown University, Providence, RI
- Center of Innovation in Long-Term Services and Supports, Veterans Administration (VA) Medical Center, Providence, Rhode Island
| | - Yi Cao
- Ragon Institute of MGH, MIT and Harvard, Cambridge, MA
| | - Philip A Chan
- Warren Alpert Medical School, Brown University, Providence, RI
- Rhode Island Department of Health, Providence, RI
| | - Christopher W Halladay
- Center of Innovation in Long-Term Services and Supports, Veterans Administration (VA) Medical Center, Providence, Rhode Island
| | - Kevin W McConeghy
- Center of Innovation in Long-Term Services and Supports, Veterans Administration (VA) Medical Center, Providence, Rhode Island
| | - Clare Nugent
- Warren Alpert Medical School, Brown University, Providence, RI
| | - Jürgen Bosch
- Case Western Reserve University School of Medicine, Cleveland, OH
| | | | - Brigid M Wilson
- Geriatric Research Education and Clinical Center, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio
| | | | - Elizabeth M White
- Warren Alpert Medical School, Brown University, Providence, RI
- Department of Health Services, Policy & Practice, School of Public Health, Brown University, Providence, Rhode Island
| | - David H Canaday
- Case Western Reserve University School of Medicine, Cleveland, OH
- Geriatric Research Education and Clinical Center, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio
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14
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Nugent C, Abul Y, White EM, Shehadeh F, Kaczynski M, Oscar Felix L, Ganesan N, Oyebanji OA, Vishnepolskiy I, Didion EM, Paxitzis A, Sheehan ML, Chan PA, Pfeifer WM, Dickerson E, Kamojjala S, Wilson BM, Mylonakis E, King CL, Balazs AB, Canaday DH, Gravenstein S. Second monovalent SARS-CoV-2 mRNA booster restores Omicron-specific neutralizing activity in both nursing home residents and health care workers. Vaccine 2023; 41:3403-3409. [PMID: 37117056 PMCID: PMC10123357 DOI: 10.1016/j.vaccine.2023.04.034] [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] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 04/04/2023] [Accepted: 04/11/2023] [Indexed: 04/30/2023]
Abstract
We examined whether the second monovalent SARS-CoV-2 mRNA booster increased antibody levels and their neutralizing activity to Omicron variants in nursing home residents (NH) residents and healthcare workers (HCW). We sampled 376 NH residents and 63 HCW after primary mRNA vaccination, first and second boosters, for antibody response and pseudovirus neutralization assay against SARS-CoV-2 wild-type (WT) (Wuhan-Hu-1) strain, Omicron BA.1 and BA.5 variants. Antibody levels and neutralizing activity progressively increased with each booster but subsequently waned over 3-6 months. NH residents, both those without and with prior infection, had a robust geometric mean fold rise (GMFR) of 8.1 (95% CI 4.4, 14.8) and 7.8 (95% CI 4.8, 12.9) respectively in Omicron-BA.1 subvariant specific neutralizing antibody levels following the second booster vaccination (p < 0.001). These results support the ongoing efforts to ensure that both NH residents and HCW are up-to-date on recommended SARS-CoV-2 vaccine booster doses.
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Affiliation(s)
- Clare Nugent
- Division of Geriatrics and Palliative Medicine, Alpert Medical School of Brown University, Providence, RI, United States
| | - Yasin Abul
- Division of Geriatrics and Palliative Medicine, Alpert Medical School of Brown University, Providence, RI, United States; Center on Innovation in Long-Term Services and Supports, Providence Veterans Administration Medical Center, Providence, RI, United States; Brown University School of Public Health Center for Gerontology and Healthcare Research, Providence, RI, United States
| | - Elizabeth M White
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, United States
| | - Fadi Shehadeh
- Division of Infectious Diseases, Alpert Medical School of Brown University, Providence, RI, United States
| | - Matthew Kaczynski
- Division of Infectious Diseases, Alpert Medical School of Brown University, Providence, RI, United States
| | - Lewis Oscar Felix
- Division of Infectious Diseases, Alpert Medical School of Brown University, Providence, RI, United States
| | - Narchonai Ganesan
- Division of Infectious Diseases, Alpert Medical School of Brown University, Providence, RI, United States
| | - Oladayo A Oyebanji
- Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Igor Vishnepolskiy
- Division of Geriatrics and Palliative Medicine, Alpert Medical School of Brown University, Providence, RI, United States; Center on Innovation in Long-Term Services and Supports, Providence Veterans Administration Medical Center, Providence, RI, United States
| | - Elise M Didion
- Geriatric Research, Education and Clinical Center, VA Northeast Ohio Healthcare System, Cleveland VA, United States
| | - Alexandra Paxitzis
- Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Maegan L Sheehan
- Ragon Institute of MGH, MIT and Harvard, Cambridge, MA, United States
| | - Philip A Chan
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, United States
| | | | - Evan Dickerson
- Division of Geriatrics and Palliative Medicine, Alpert Medical School of Brown University, Providence, RI, United States; Center on Innovation in Long-Term Services and Supports, Providence Veterans Administration Medical Center, Providence, RI, United States
| | - Shreya Kamojjala
- Division of Geriatrics and Palliative Medicine, Alpert Medical School of Brown University, Providence, RI, United States
| | - Brigid M Wilson
- Case Western Reserve University School of Medicine, Cleveland, OH, United States; Geriatric Research, Education and Clinical Center, VA Northeast Ohio Healthcare System, Cleveland VA, United States
| | - Eleftherios Mylonakis
- Division of Infectious Diseases, Alpert Medical School of Brown University, Providence, RI, United States
| | - Christopher L King
- Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | | | - David H Canaday
- Case Western Reserve University School of Medicine, Cleveland, OH, United States; Geriatric Research, Education and Clinical Center, VA Northeast Ohio Healthcare System, Cleveland VA, United States.
| | - Stefan Gravenstein
- Division of Geriatrics and Palliative Medicine, Alpert Medical School of Brown University, Providence, RI, United States; Center on Innovation in Long-Term Services and Supports, Providence Veterans Administration Medical Center, Providence, RI, United States; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, United States.
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15
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Kazemain E, Figueiredo J, Skarbinski J, McBride R, Simon V, Karger AB, Lee FEH, Hirsch FR, Cox A, Klein S, Fan R, Halene S, Zidar DA, Crawford JM, Thyagarajan B, Gleason C, Mathson A, Srivastava K, Moshele P, Amoss T, Runnstrom M, Linderman S, Rodilla AM, Mack PC, Shyr Y, Yin A, Shea P, VanOudenhove J, Siddiqui H, Wilson BM, Elkin EP, Hsiao CA, Ziemba Y, Schleicher CB, Fox S, Kushi LH, Reckamp K, Merchant A, Merin N. Abstract 798: SeroNet Pooling Project of immunocompromised populations. Cancer Res 2023. [DOI: 10.1158/1538-7445.am2023-798] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
Abstract
Introduction: COVID-19 vaccination substantially reduces morbidity and mortality associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and severe illness. However, despite effective COVID-19 vaccines many questions remain about the efficacy of vaccines and the durability and robustness of immune responses, especially in immunocompromised persons. The NCI-funded Serological Sciences Network (SeroNet) is a coordinated effort including 11 sites to advance research on the immune response to SARS-CoV-2 infection and COVID-19 vaccination among diverse and vulnerable populations. The goals of the Pooling Project are: (1) to conduct real-world data (RWD) analyses using electronic medical records (EMR) data from four health care systems (Kaiser Permanente Northern California, Northwell Health, Veterans Affairs-Case Western, and Cedars-Sinai) to determine vaccine effectiveness in (a) cancer patients; (b) autoimmune diseases and (c) solid organ transplant recipients (SOTR); (2) to conduct meta-analyses of prospective cohort studies from eight SeroNet institutions (Cedars-Sinai, Johns Hopkins, Northwell Health, Emory University, University of Minnesota, Mount Sinai, Yale University) to determine post-vaccine immune responses in (a) lung cancer patients; (b) hematologic cancers/hematopoietic stem cell transplant (HSCT) recipients; (c) SOTR; (d) lupus.
Methods: For our RWD analyses, data is extracted from EMR using standardized algorithms using ICD-10 codes to identify immunocompromised persons (hematologic and solid organ malignancy; SOTR; autoimmune disease, including inflammatory bowel disease, rheumatoid arthritis, and SLE). We use common case definitions to extract data on demographic, laboratory values, clinical co-morbidity, COVID-19 vaccination, SARS-CoV-2 infection and severe COVID-19, and disease-specific variables. In addition, we pool individual-level data from prospective cohorts enrolling patients with cancer and other immunosuppressed conditions from across network. Surveys and biospecimens from serology and immune profiling are collected at pre-specified timepoints across longitudinal cohorts.
Results: Currently, we have EMR data extracted from 4 health systems including >715,000 cancer patients, >9,500 SOTR and >180,000 with autoimmune conditions. Prospective cohorts across the network have longitudinal data on >450 patients with lung cancer, >1,200 patients with hematologic malignancies, >400 SOTR and >400 patients with lupus. We will report results examining vaccine effectiveness for prevention of SARS-CoV-2 infection, severe COVID-19 and post-acute sequelae of COVID-19 (PAS-C or long COVID) in cancer patients compared to other immunocompromised conditions.
Conclusion: Our goal is to inform public health guidelines on COVID-19 vaccine and boosters to reduce SARS-CoV-2 infection and severe illness in immunocompromised populations.
Citation Format: Elham Kazemain, Jane Figueiredo, Jacek Skarbinski, Russell McBride, Viviana Simon, Amy B. Karger, F. Eun-Hyung Lee, Fred R. Hirsch, Andrea Cox, Sabra Klein, Rong Fan, Stephanie Halene, David A. Zidar, James M. Crawford, Bharat Thyagarajan, Charles Gleason, Alex Mathson, Komal Srivastava, Puleng Moshele, Toby Amoss, Martin Runnstrom, Susanne Linderman, Ananda M. Rodilla, Philip C. Mack, Yu Shyr, Anna Yin, Patrick Shea, Jennifer VanOudenhove, Hinnah Siddiqui, Brigid M. Wilson, Eric P. Elkin, Crystal A. Hsiao, Yonah Ziemba, Cheryl B. Schleicher, Sharon Fox, Lawrence H. Kushi, Karen Reckamp, Akil Merchant, Noah Merin. SeroNet Pooling Project of immunocompromised populations [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 798.
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Affiliation(s)
| | | | | | | | - Viviana Simon
- 3Icahn School of Medicine at Mount Sinai, New York, NY
| | | | | | | | - Andrea Cox
- 6John Hopkins University School of Medicine, Baltimore, MD
| | - Sabra Klein
- 7Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Rong Fan
- 8Yale School of Medicine, New Haven, CT
| | | | - David A. Zidar
- 9Case Western Reserve University School of Medicine, Cleveland, OH
| | - James M. Crawford
- 10Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, Hempstead, NY
| | | | | | | | | | | | | | | | | | | | | | - Yu Shyr
- 14Vanderbilt University, Nashville, TN
| | - Anna Yin
- 6John Hopkins University School of Medicine, Baltimore, MD
| | - Patrick Shea
- 6John Hopkins University School of Medicine, Baltimore, MD
| | | | - Hinnah Siddiqui
- 16Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, OH
| | - Brigid M. Wilson
- 16Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, OH
| | | | | | - Yonah Ziemba
- 10Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, Hempstead, NY
| | - Cheryl B. Schleicher
- 10Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, Hempstead, NY
| | - Sharon Fox
- 10Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, Hempstead, NY
| | | | | | | | - Noah Merin
- 1Cedars-Sinai Medical Center, Los Angeles, CA
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16
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Curry SR, Hecker MT, O'Hagan J, Kutty PK, Alhmidi H, Ng-Wong YK, Cadnum JL, Jencson AL, Gonzalez-Orta M, Saldana C, Wilson BM, Donskey CJ. Natural history of Clostridioides difficile colonization and infection following new acquisition of carriage in healthcare settings: A prospective cohort study. Clin Infect Dis 2023:7076061. [PMID: 36905149 DOI: 10.1093/cid/ciad142] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/23/2023] [Accepted: 03/09/2023] [Indexed: 03/12/2023] Open
Abstract
BACKGROUND Limited information is available on the natural history of Clostridioides difficile colonization and infection in patients with new acquisition of C. difficile in healthcare settings. METHODS In 3 hospitals and affiliated long-term care facilities, we collected serial perirectal cultures from patients with no diarrhea on enrollment to identify new acquisition of toxigenic C. difficile carriage and determined the duration and burden of carriage. Asymptomatic carriage was defined as transient if only 1 culture was positive with negative cultures before and after or persistent if 2 or more cultures were positive. Clearance of carriage was defined as 2 consecutive negative perirectal cultures. RESULTS Of 1,432 patients with negative initial cultures and at least 1 follow-up culture, 39 (2.7%) developed CDI without prior detection of carriage and 142 (9.9%) acquired asymptomatic carriage with 19 (13.4%) subsequently diagnosed with CDI. Of 82 patients analyzed for persistence of carriage, 50 (61.0%) had transient carriage and 32 (39.0%) had persistent carriage, with an estimated median of 77 days to clearance of colonization (range, 14 to 133 days). Most persistent carriers had a relatively high burden of carriage and maintained the same ribotype over time, whereas most transient carriers had a low burden of carriage detected only using broth enrichment cultures. CONCLUSIONS In 3 healthcare facilities, 9.9% of patients acquired asymptomatic carriage of toxigenic C. difficile, and 13.4% were subsequently diagnosed with CDI. Most carriers had transient rather than persistent carriage and most patients developing CDI did not have prior detection of carriage.
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Affiliation(s)
- Scott R Curry
- Division of Infectious Diseases, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Michelle T Hecker
- Division of Infectious Diseases, MetroHealth Medical Center, Cleveland, Ohio, USA.,Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Justin O'Hagan
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Preeta K Kutty
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Heba Alhmidi
- Research Service, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio, USA
| | - Yilen K Ng-Wong
- Research Service, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio, USA
| | - Jennifer L Cadnum
- Research Service, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio, USA
| | - Annette L Jencson
- Research Service, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio, USA
| | - Melany Gonzalez-Orta
- Research Service, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio, USA
| | - Carlos Saldana
- Research Service, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio, USA
| | - Brigid M Wilson
- Geriatric Research, Education, and Clinical Center, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio, USA
| | - Curtis J Donskey
- Division of Infectious Diseases, MetroHealth Medical Center, Cleveland, Ohio, USA.,Geriatric Research, Education, and Clinical Center, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio, USA
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17
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Canaday DH, Oyebanji OA, White EM, Bosch J, Nugent C, Vishnepolskiy I, Abul Y, Didion EM, Paxitzis A, Sundheimer N, Ragavapuram V, Wilk D, Keresztesy D, Cao Y, St. Denis K, McConeghy KW, McDonald LC, Jernigan JA, Mylonakis E, Wilson BM, King CL, Balazs AB, Gravenstein S. SARS-CoV-2 Antibody Responses to the Ancestral SARS-CoV-2 Strain and Omicron BA.1 and BA.4/BA.5 Variants in Nursing Home Residents After Receipt of Bivalent COVID-19 Vaccine - Ohio and Rhode Island, September-November 2022. MMWR Morb Mortal Wkly Rep 2023; 72:100-106. [PMID: 36701254 PMCID: PMC9925133 DOI: 10.15585/mmwr.mm7204a4] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Introduction of monovalent COVID-19 mRNA vaccines in late 2020 helped to mitigate disproportionate COVID-19-related morbidity and mortality in U.S. nursing homes (1); however, reduced effectiveness of monovalent vaccines during the period of Omicron variant predominance led to recommendations for booster doses with bivalent COVID-19 mRNA vaccines that include an Omicron BA.4/BA.5 spike protein component to broaden immune response and improve vaccine effectiveness against circulating Omicron variants (2). Recent studies suggest that bivalent booster doses provide substantial additional protection against SARS-CoV-2 infection and severe COVID-19-associated disease among immunocompetent adults who previously received only monovalent vaccines (3).* The immunologic response after receipt of bivalent boosters among nursing home residents, who often mount poor immunologic responses to vaccines, remains unknown. Serial testing of anti-spike protein antibody binding and neutralizing antibody titers in serum collected from 233 long-stay nursing home residents from the time of their primary vaccination series and including any subsequent booster doses, including the bivalent vaccine, was performed. The bivalent COVID-19 mRNA vaccine substantially increased anti-spike and neutralizing antibody titers against Omicron sublineages, including BA.1 and BA.4/BA.5, irrespective of previous SARS-CoV-2 infection or previous receipt of 1 or 2 booster doses. These data, in combination with evidence of low uptake of bivalent booster vaccination among residents and staff members in nursing homes (4), support the recommendation that nursing home residents and staff members receive a bivalent COVID-19 booster dose to reduce associated morbidity and mortality (2).
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Nugent C, Abul Y, White E, Shehadeh F, Kaczynski M, Felix LO, Ganesan N, Oyebanji OA, Vishnepolskiy I, Didion EM, Paxitzis A, Sheehan ML, Mylonakis E, Wilson BM, Balazs AB, Chan PA, King CL, Pfeifer WM, Dickerson E, Canaday DH, Gravenstein S. Second monovalent SARS-CoV-2 mRNA booster restores Omicron-specific neutralizing activity in both nursing home residents and health care workers. medRxiv 2023:2023.01.22.23284881. [PMID: 36747765 PMCID: PMC9901038 DOI: 10.1101/2023.01.22.23284881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
We examined whether the second monovalent SARS-CoV-2 mRNA booster increased antibody levels and their neutralizing activity to Omicron variants in nursing home residents (NH) residents and healthcare workers (HCW). We sampled 367 NH residents and 60 HCW after primary mRNA vaccination, first and second boosters, for antibody response and pseudovirus neutralization assay against SARS-CoV-2 wild-type (WT) (Wuhan-Hu-1) strain and Omicron BA1 variant. Antibody levels and neutralizing activity progressively increased with each booster but subsequently waned over weeks. NH residents, both those without and with prior infection, had a robust geometric mean fold rise (GMFR) of 10.2 (95% CI 5.1, 20.3) and 6.5 (95% CI 4.5, 9.3) respectively in Omicron-BA.1 subvariant specific neutralizing antibody levels following the second booster vaccination (p<0.001). These results support the ongoing efforts to ensure that both NH residents and HCW are up to date on recommended SARS-CoV-2 vaccine booster doses.
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Ha W, Stiefel MA, Gries JR, Cadnum JL, Torres-Teran MM, Wilson BM, Donskey CJ. Evaluation of Interventions to Improve Ventilation in Households to Reduce Risk for Transmission of Severe Acute Respiratory Syndrome Coronavirus 2. Pathog Immun 2022; 7:120-130. [PMID: 36655199 PMCID: PMC9836208 DOI: 10.20411/pai.v7i2.553] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 10/11/2022] [Accepted: 11/19/2022] [Indexed: 12/14/2022] Open
Abstract
Background Inadequate ventilation may contribute to the high risk for household transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Methods We evaluated the effectiveness of several interventions recommended to improve ventilation in households. In 7 residential homes, carbon dioxide monitoring was conducted to assess ventilation in occupied open areas such as family rooms and in bedrooms and/or offices. Carbon dioxide levels above 800 parts per million (ppm) were considered an indicator of suboptimal ventilation for the number of people present. In 1 of the 7 homes, various interventions to improve ventilation or to filter air were assessed in a kitchen area by measuring clearance of aerosol particles produced using an aerosol-based spray system and carbon dioxide generated by cooking with a gas stove. Results Carbon dioxide levels rose above 800 ppm in bedrooms and offices with 2 occupants when windows and doors were closed and in open areas during gatherings of 5 to 10 people; carbon dioxide levels decreased when windows or doors were opened. Clearance of carbon dioxide and aerosol particles significantly increased with interventions including running fans, operating portable air cleaners, and opening windows, particularly when there was a noticeable breeze or when a window fan was used to blow contaminated air outside. Conclusion In households, several measures to improve ventilation or air filtration were effective in reducing carbon dioxide accumulation or enhancing clearance of carbon dioxide and aerosol particles. Studies are needed to determine if interventions to improve ventilation can reduce the risk for airborne transmission of SARS-CoV-2 in households.
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Affiliation(s)
- Wilson Ha
- John Carroll University, University Heights, Ohio
| | | | | | - Jennifer L. Cadnum
- Research Service, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio
| | | | - Brigid M. Wilson
- Geriatric Research, Education, and Clinical Center, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio
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Cadnum JL, Jencson AL, Memic S, Osborne AO, Torres-Teran MM, Wilson BM, Deshpande A, Donskey CJ. Real-World Evidence on the Effectiveness of Plexiglass Barriers in Reducing Aerosol Exposure. Pathog Immun 2022; 7:66-77. [PMID: 36381131 PMCID: PMC9651177 DOI: 10.20411/pai.v7i2.533] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 10/13/2022] [Indexed: 08/17/2023] Open
Abstract
UNLABELLED Reprinted with permission, Cleveland Clinic Foundation ©2022. All Rights Reserved. BACKGROUND Barriers are commonly installed in workplace situations where physical distancing cannot be maintained to reduce the risk for transmission of respiratory viruses. Although some types of barriers have been shown to reduce exposure to aerosols in laboratory-based testing, limited information is available on the efficacy of barriers in real-world settings. METHODS In an acute care hospital, we tested the effectiveness of in-use plexiglass barriers in reducing exposure of staff to aerosolized particles. A nebulizer was used to release 5% NaCl aerosol 1 meter from staff members with and without the barrier positioned between the point of aerosol release and the hospital staff. Particle counts on the staff side of the barrier were measured using a 6-channel particle counter. A condensed moisture (fog) generating device was used to visualize the airflow patterns. RESULTS Of 13 in-use barriers tested, 6 (46%) significantly reduced aerosol particle counts detected behind the barrier, 6 (46%) reduced particle counts to a modest, non-significant degree, and 1 (8%) significantly increased particle counts behind the barrier. Condensed moisture fog accumulated in the area where staff were seated behind the barrier that increased particle exposure, but not behind the other barriers. After repositioning the ineffective barrier, the condensed moisture fog no longer accumulated behind the barrier and aerosol exposure was reduced. CONCLUSION In real-world settings, plexiglass barriers vary widely in effectiveness in reducing staff exposure to aerosols, and some barriers may increase risk for exposure if not positioned correctly. Devices that visualize airflow patterns may be useful as simple tools to assess barriers.
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Affiliation(s)
- Jennifer L. Cadnum
- Research Service, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio
| | - Annette L. Jencson
- Research Service, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio
| | - Samir Memic
- Research Service, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio
| | | | | | - Brigid M. Wilson
- Case Western Reserve University School of Medicine, Cleveland, Ohio
- Geriatric Research, Education, and Clinical Center, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio
| | - Abhishek Deshpande
- Center for Value-Based Care Research, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - Curtis J. Donskey
- Case Western Reserve University School of Medicine, Cleveland, Ohio
- Geriatric Research, Education, and Clinical Center, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio
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21
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Torres-Teran MM, Alhmidi H, Koganti S, Jencson AL, Cadnum JL, Wilson BM, Donskey CJ. Dissemination of methicillin-resistant Staphylococcus aureus and bacteriophage MS2 from floors in long-term care facility resident rooms. Am J Infect Control 2022; 51:714-717. [PMID: 36195154 DOI: 10.1016/j.ajic.2022.09.024] [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] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 09/24/2022] [Accepted: 09/26/2022] [Indexed: 11/29/2022]
Abstract
We demonstrated that methicillin-resistant Staphylococcus aureus (MRSA) contamination on floors in the rooms of colonized long-term care facility residents was frequently transferred by shoes to adjacent patient rooms. A benign virus inoculated onto the floor was transferred to floors and high-touch surfaces in adjacent rooms and the nursing station. These results suggest that shoes may serve as a vector for dissemination of healthcare-associated pathogens from rooms of MRSA-colonized patients.
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Affiliation(s)
| | - Heba Alhmidi
- Research Service, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio
| | - Sreelatha Koganti
- Research Service, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio
| | - Annette L Jencson
- Research Service, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio
| | - Jennifer L Cadnum
- Research Service, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio
| | - Brigid M Wilson
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Curtis J Donskey
- Geriatric Research, Education and Clinical Center, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio.
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Mongilardi N, Wilson BM, Bej TA, Briggs JM, Banks RE, Song S, Jump RLP, Perez F. Group B Streptococcus in the urine in nonpregnant adults: Disease or distraction? Antimicrob Steward Healthc Epidemiol 2022; 2:e131. [PMID: 36483389 PMCID: PMC9726585 DOI: 10.1017/ash.2022.236] [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] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 05/12/2022] [Accepted: 05/13/2022] [Indexed: 06/17/2023]
Abstract
In this large, retrospective cohort study, we used administrative data to evaluate nonpregnant adults with group B Streptococcus (GBS) bacteriuria. We found greater all-cause mortality in those with urinary tract infections compared to asymptomatic bacteriuria. Differences in patients' baseline characteristics and the 1-year mortality rate raise the possibility that provider practices contribute to differences observed.
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Affiliation(s)
- Nicole Mongilardi
- Geriatric Research Education and Clinical Center (GRECC), VA Northeast Ohio Healthcare System, Cleveland, Ohio
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, Cleveland Institute for Computational Biology, Cleveland, Ohio
| | - Brigid M. Wilson
- Geriatric Research Education and Clinical Center (GRECC), VA Northeast Ohio Healthcare System, Cleveland, Ohio
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, Cleveland Institute for Computational Biology, Cleveland, Ohio
| | - Taissa A. Bej
- Geriatric Research Education and Clinical Center (GRECC), VA Northeast Ohio Healthcare System, Cleveland, Ohio
| | - Janet M. Briggs
- Geriatric Research Education and Clinical Center (GRECC), VA Northeast Ohio Healthcare System, Cleveland, Ohio
| | - Richard E. Banks
- Geriatric Research Education and Clinical Center (GRECC), VA Northeast Ohio Healthcare System, Cleveland, Ohio
| | - Sunah Song
- Cleveland Institute for Computational Biology, Cleveland, Ohio
| | - Robin L. P. Jump
- Geriatric Research Education and Clinical Center (GRECC), VA Northeast Ohio Healthcare System, Cleveland, Ohio
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, Cleveland Institute for Computational Biology, Cleveland, Ohio
- Department of Population and Quantitative Health Sciences at Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Federico Perez
- Geriatric Research Education and Clinical Center (GRECC), VA Northeast Ohio Healthcare System, Cleveland, Ohio
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, Cleveland Institute for Computational Biology, Cleveland, Ohio
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23
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Canaday DH, Oyebanji OA, White E, Keresztesy D, Payne M, Wilk D, Carias L, Aung H, St Denis K, Sheehan ML, Berry SD, Cameron CM, Cameron MJ, Wilson BM, Balazs AB, King CL, Gravenstein S. COVID-19 vaccine booster dose needed to achieve Omicron-specific neutralisation in nursing home residents. EBioMedicine 2022; 80:104066. [PMID: 35605428 PMCID: PMC9122310 DOI: 10.1016/j.ebiom.2022.104066] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [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: 02/01/2022] [Revised: 04/26/2022] [Accepted: 05/02/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Nursing home (NH) residents have borne a disproportionate share of SARS-CoV-2 morbidity and mortality. Vaccines have limited hospitalisation and death from earlier variants in this vulnerable population. With the rise of Omicron and future variants, it is vital to sustain and broaden vaccine-induced protection. We examined the effect of boosting with BNT162b2 mRNA vaccine on humoral immunity and Omicron-specific neutralising activity among NH residents and healthcare workers (HCWs). METHODS We longitudinally enrolled 85 NH residents (median age 77) and 48 HCWs (median age 51), and sampled them after the initial vaccination series; and just before and 2 weeks after booster vaccination. Anti-spike, anti-receptor binding domain (RBD) and neutralisation titres to the original Wuhan strain and neutralisation to the Omicron strain were obtained. FINDINGS Booster vaccination significantly increased vaccine-specific anti-spike, anti-RBD, and neutralisation levels above the pre-booster levels in NH residents and HCWs, both in those with and without prior SARS-CoV-2 infection. Omicron-specific neutralisation activity was low after the initial 2 dose series with only 28% of NH residents' and 28% HCWs' titres above the assay's lower limit of detection. Omicron neutralising activity following the booster lifted 86% of NH residents and 93% of HCWs to the detectable range. INTERPRETATION With boosting, the vast majority of HCWs and NH residents developed detectable Omicron-specific neutralising activity. These data provide immunologic evidence that strongly supports booster vaccination to broaden neutralising activity and counter waning immunity in the hope it will better protect this vulnerable, high-risk population against the Omicron variant. FUNDING NIH AI129709-03S1, U01 CA260539-01, CDC 200-2016-91773, and VA BX005507-01.
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Affiliation(s)
- David H Canaday
- Case Western Reserve University School of Medicine, Cleveland, OH; Geriatric Research, Education and Clinical Center, Cleveland VA.
| | | | - Elizabeth White
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
| | | | - Michael Payne
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Dennis Wilk
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Lenore Carias
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Htin Aung
- Case Western Reserve University School of Medicine, Cleveland, OH
| | | | | | - Sarah D Berry
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Cheryl M Cameron
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Mark J Cameron
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Brigid M Wilson
- Geriatric Research, Education and Clinical Center, Cleveland VA
| | | | | | - Stefan Gravenstein
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI; Center on Innovation in Long-Term Services and Supports, Providence Veterans Administration Medical Center, Providence, RI; Division of Geriatrics and Palliative Medicine, Alpert Medical School of Brown University, Providence, RI
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24
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Banks RE, Wilson BM, Bej T, Briggs JM, Song S, Goto M, Jump RLP, Perez F. Similar Mortality among United States Veterans with Invasive and Non-Invasive Pneumonia due to Group B Streptococcus. Open Forum Infect Dis 2022; 9:ofac051. [DOI: 10.1093/ofid/ofac051] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 01/27/2022] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
The nosology of non-invasive pneumonia due to Group B Streptococcus (GBS) is not well defined. This study compared clinical characteristics and outcomes of patients with invasive pneumonia and non-invasive pneumonia caused by GBS.
Methods
We conducted a retrospective cohort study among Veterans Affairs (VA) healthcare users between 2008 and 2017. Using data from electronic health records, we identified patients who had blood or respiratory cultures that grew GBS and had invasive pneumonia or non-invasive pneumonia. We analyzed patient and infection characteristics associated with all-cause mortality, including among the subset of patients with cultures that were monomicrobial for GBS.
Results
Among 1791 patients with GBS pneumonia, 646 (36%) cases were invasive and 1145 (64%) were non-invasive. Among those, 535 and 424 cases of invasive and non-invasive pneumonia, respectively, had cultures that were monomicrobial for GBS. All-cause 30-day mortality among those with monomicrobial GBS pneumonia was 15% for both those with invasive and non-invasive disease, respectively. Increasing age, severity of illness, healthcare exposure in the previous 90 days, and polymicrobial infection with Staphylococcus aureus were independently associated with all-cause mortality at 30 days.
Conclusions
In this large cohort, even when considering cases for which GBS was the only pathogen recovered, more than 40% of GBS pneumonia cases were non-invasive. All cause-mortality was comparable for invasive and non-invasive pneumonia. These findings suggests that the burden of GBS pneumonia may be greater than previously recognized by surveillance of invasive GBS disease and may inform treatment and prevention efforts.
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Affiliation(s)
- Richard E Banks
- Geriatric Research Education and Clinical Center, VA Northeast Ohio Healthcare System, Cleveland, Ohio, United States of America
| | - Brigid M Wilson
- Geriatric Research Education and Clinical Center, VA Northeast Ohio Healthcare System, Cleveland, Ohio, United States of America
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America
| | - Taissa Bej
- Geriatric Research Education and Clinical Center, VA Northeast Ohio Healthcare System, Cleveland, Ohio, United States of America
| | - Janet M Briggs
- Geriatric Research Education and Clinical Center, VA Northeast Ohio Healthcare System, Cleveland, Ohio, United States of America
| | - Sunah Song
- Cleveland Institute for Computational Biology, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America
| | - Michihiko Goto
- Center for Comprehensive Access & Delivery Research & Evaluation (CADRE), Iowa City VA Healthcare System, Iowa City, Iowa, United States of America
- Department of Internal Medicine, Division of Infectious Diseases, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa, United States of America
| | - Robin L P Jump
- Geriatric Research Education and Clinical Center, VA Northeast Ohio Healthcare System, Cleveland, Ohio, United States of America
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America
| | - Federico Perez
- Geriatric Research Education and Clinical Center, VA Northeast Ohio Healthcare System, Cleveland, Ohio, United States of America
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America
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Canaday DH, Oyebanji OA, White E, Keresztesy D, Payne M, Wilk D, Carias L, Aung H, St Denis K, Sheehan ML, Berry SD, Cameron CM, Cameron MJ, Wilson BM, Balazs AB, King CL, Gravenstein S. Significantly elevated antibody levels and neutralization titers in nursing home residents after SARS-CoV-2 BNT162b2 mRNA booster vaccination. medRxiv 2021:2021.12.07.21267179. [PMID: 34909792 PMCID: PMC8669859 DOI: 10.1101/2021.12.07.21267179] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Nursing home (NH) residents have experienced significant morbidity and mortality to SARS-CoV-2 throughout the pandemic. Vaccines initially curbed NH resident morbidity and mortality, but antibody levels and protection have declined with time since vaccination, prompting introduction of booster vaccination. This study assesses humoral immune response to booster vaccination in 85 NH residents and 44 health care workers (HCW) that we have followed longitudinally since initial SARS-CoV-2 BNT162b2 mRNA vaccination. The findings reveal that booster vaccination significantly increased anti-spike, anti-receptor binding domain, and neutralization titers above the pre-booster levels in almost all NH residents and HCW to significantly higher levels than shortly after the completion of the initial vaccine series. These data support the CDC recommendation to offer vaccine boosters to HCWs and NH residents on an immunological basis. Notably, even the older, more frail and more multi-morbid NH residents have sizable antibody increases with boosting.
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Affiliation(s)
- David H Canaday
- Case Western Reserve University School of Medicine, Cleveland, OH
- Geriatric Research, Education and Clinical Center, Cleveland VA
| | | | - Elizabeth White
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
| | | | - Michael Payne
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Dennis Wilk
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Lenore Carias
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Htin Aung
- Case Western Reserve University School of Medicine, Cleveland, OH
| | | | | | - Sarah D Berry
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Cheryl M Cameron
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Mark J Cameron
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Brigid M Wilson
- Geriatric Research, Education and Clinical Center, Cleveland VA
| | | | | | - Stefan Gravenstein
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
- Division of Geriatrics and Palliative Medicine, Alpert Medical School of Brown University, Providence, RI
- Center on Innovation in Long-Term Services and Supports, Providence Veterans Administration Medical Center, Providence, RI
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Huded JM, Lee A, Song S, McQuown CM, Wilson BM, Smith TI, Bonomo RA. Association of a geriatric emergency department program with healthcare outcomes among veterans. J Am Geriatr Soc 2021; 70:601-608. [PMID: 34820827 DOI: 10.1111/jgs.17572] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 11/03/2021] [Accepted: 11/03/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND We aim to describe the outcomes of Geriatric Emergency Room Innovations for Veterans (GERI-VET), the first comprehensive Veterans Affairs Geriatric ED program. METHODS In this prospective observational cohort study at an urban Veterans Affairs Medical Center ED, participants included Veterans aged 65 years and older treated in the ED from January 7, 2017 to February 29, 2020. Veterans with an Identification of Seniors At Risk (ISAR) score >2 were considered eligible for GERI-VET, receiving geriatric screens and care coordination in addition to standard ED treatment. The control group included GERI-VET eligible Veterans who did not receive GERI-VET care. Propensity score matching was used to compare outcomes in the GERI-VET group (N = 725) and a matched control group (n = 725). Key measures included ED resource utilization, outpatient referrals, ED admission, and 30-day admission. RESULTS In the ED, the GERI-VET group received more consults to pharmacy (315 [43.4%] vs. 195 [26.9%], p < 0.001) and social work (399 [55.0%] vs. 132 [18.2%], p < 0.001). The GERI-VET group had higher referral rates to Geriatrics (64 [17.7%] vs. 18 [5.8%], p < 0.001) and Home Based Primary Care (110 [30.4%] vs. 24 [7.8%], p < 0.001). Key outcome measures included lower rates of ED admission (363 [50.1%] vs. 417 [n = 57.5%], p = 0.003) and 30-day hospital admission (412 [56.8%] vs. 464 [64.0%], p = 0.004) without increasing ED length of stay (5.4 ± 2.2 vs. 5.4 ± 2.6 h, p = 0.85) or 72-h ED revisits (23 [3.2%] vs. 16 [2.2%], p = 0.25) in the GERI-VET group. CONCLUSIONS A program designed to screen for geriatric syndromes and coordinate care among at-risk older Veterans was associated with increased multidisciplinary resource utilization and reduced ED and 30-day admissions without increasing ED length of stay or re-visitation.
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Affiliation(s)
- Jill M Huded
- Department of Medicine, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Albert Lee
- Medicine Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA
| | - Sunah Song
- Cleveland Geriatric Research Education and Clinical Centers, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio, USA.,Cleveland Institute for Computational Biology, Case Western Reserve University, Cleveland, Ohio, USA
| | - Colleen M McQuown
- Medicine Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA
| | - Brigid M Wilson
- Cleveland Geriatric Research Education and Clinical Centers, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio, USA
| | - Todd I Smith
- Medicine Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA.,Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Robert A Bonomo
- Medicine Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA.,Cleveland Geriatric Research Education and Clinical Centers, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio, USA.,Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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Canaday DH, Oyebanji OA, Keresztesy D, Payne M, Wilk D, Carias L, Aung H, St. Denis K, Lam EC, Rowley CF, Berry SD, Cameron CM, Cameron MJ, Wilson BM, Balazs AB, King CL, Gravenstein S. Significant Reduction in Vaccine-Induced Antibody Levels and Neutralization Activity Among Healthcare Workers and Nursing Home Residents 6 Months Following Coronavirus Disease 2019 BNT162b2 mRNA Vaccination. Clin Infect Dis 2021; 75:e884-e887. [PMID: 35174389 PMCID: PMC9402619 DOI: 10.1093/cid/ciab963] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Indexed: 01/19/2023] Open
Abstract
Antibody decline occurred from 2 weeks to 6 months post-BNT162b2 mRNA vaccination in nursing home (NH) residents and healthcare workers. Antispike, receptor-binding domain, and neutralization levels dropped >81% irrespective of prior infection. Notably, 69% of infection-naive NH residents had neutralizing antibodies at or below the assay's limit of detection.
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Affiliation(s)
- David H Canaday
- Correspondence: D. H. Canaday, Case Western Reserve University School of Medicine, 10900 Euclid Ave, BRB 1022, Cleveland, OH 44106-4984 ()
| | - Oladayo A Oyebanji
- Division of Infectious Disease, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Debbie Keresztesy
- Division of Infectious Disease, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Michael Payne
- Division of Infectious Disease, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Dennis Wilk
- Division of Infectious Disease, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Lenore Carias
- Division of Infectious Disease, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Htin Aung
- Division of Infectious Disease, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Kerri St. Denis
- Ragon Institute of MGH, MIT and Harvard, Cambridge, Massachusetts, USA
| | - Evan C Lam
- Ragon Institute of MGH, MIT and Harvard, Cambridge, Massachusetts, USA
| | - Christopher F Rowley
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Sarah D Berry
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Cheryl M Cameron
- Division of Infectious Disease, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Mark J Cameron
- Division of Infectious Disease, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Brigid M Wilson
- Geriatric Research, Education and Clinical Center, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio, USA
| | | | - Christopher L King
- Division of Infectious Disease, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Stefan Gravenstein
- Division of Geriatrics and Palliative Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, USA,Center on Innovation in Long-Term Services and Supports, Providence Veterans Administration Medical Center, Providence, Rhode Island, USA
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Bej T, Kothadia S, Wilson BM, Song S, Briggs JM, Banks RE, Donskey CJ, Perez F, Jump RLP. Impact of fever thresholds in detection of COVID-19 in Department of Veterans Affairs Community Living Center residents. J Am Geriatr Soc 2021; 69:3044-3050. [PMID: 34375443 PMCID: PMC8447344 DOI: 10.1111/jgs.17415] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 07/23/2021] [Accepted: 07/31/2021] [Indexed: 11/29/2022]
Abstract
Background Among nursing home residents, for whom age and frailty can blunt febrile responses to illness, the temperature used to define fever can influence the clinical recognition of COVID‐19 symptoms. To assess the potential for differences in the definition of fever to characterize nursing home residents with COVID‐19 infections as symptomatic, pre‐symptomatic, or asymptomatic, we conducted a retrospective study on a national cohort of Department of Veterans Affairs (VA) Community Living Center (CLC) residents tested for SARS‐CoV‐2. Methods Residents with positive SARS‐CoV‐2 tests were classified as asymptomatic if they did not experience any symptoms, and as symptomatic or pre‐symptomatic if the experienced a fever (>100.4°F) before or following a positive SARS‐CoV‐2 test, respectively. All‐cause 30‐day mortality was assessed as was the influence of a lower temperature threshold (>99.0°F) on classification of residents with positive SARS‐CoV‐2 tests. Results From March 2020 through November 2020, VA CLCs tested 11,908 residents for SARS‐CoV‐2 using RT‐PCR, with a positivity of rate of 13% (1557). Among residents with positive tests and using >100.4°F, 321 (21%) were symptomatic, 425 (27%) were pre‐symptomatic, and 811 (52%) were asymptomatic. All‐cause 30‐day mortality among residents with symptomatic and pre‐symptomatic COVID‐19 infections was 24% and 26%, respectively, while those with an asymptomatic infection had mortality rates similar to residents with negative SAR‐CoV‐2 tests (10% and 5%, respectively). Using >99.0°F would have increased the number of residents categorized as symptomatic at the time of testing from 321 to 773. Conclusions All‐cause 30‐day mortality was similar among VA CLC residents with symptomatic or pre‐symptomatic COVID‐19 infection, and lower than rates reported in non‐VA nursing homes. A lower temperature threshold would increase the number of residents recognized as having symptomatic infection, potentially leading to earlier detection and more rapid implementation of therapeutic interventions and infection prevention and control measures.
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Affiliation(s)
- Taissa Bej
- Geriatric Research Education and Clinical Center (GRECC), VA Northeast Ohio Healthcare System, Cleveland, Ohio, USA
| | - Sonya Kothadia
- Division of Infectious Diseases & HIV Medicine in the Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Brigid M Wilson
- Geriatric Research Education and Clinical Center (GRECC), VA Northeast Ohio Healthcare System, Cleveland, Ohio, USA.,Division of Infectious Diseases & HIV Medicine in the Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Sunah Song
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Cleveland Institute for Computational Biology, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Janet M Briggs
- Geriatric Research Education and Clinical Center (GRECC), VA Northeast Ohio Healthcare System, Cleveland, Ohio, USA
| | - Richard E Banks
- Geriatric Research Education and Clinical Center (GRECC), VA Northeast Ohio Healthcare System, Cleveland, Ohio, USA
| | - Curtis J Donskey
- Geriatric Research Education and Clinical Center (GRECC), VA Northeast Ohio Healthcare System, Cleveland, Ohio, USA.,Division of Infectious Diseases & HIV Medicine in the Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Federico Perez
- Geriatric Research Education and Clinical Center (GRECC), VA Northeast Ohio Healthcare System, Cleveland, Ohio, USA.,Division of Infectious Diseases & HIV Medicine in the Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Robin L P Jump
- Geriatric Research Education and Clinical Center (GRECC), VA Northeast Ohio Healthcare System, Cleveland, Ohio, USA.,Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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29
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Wilson BM, Jiang Y, Jump RLP, Viau RA, Perez F, Bonomo RA, Evans SR. Desirability of Outcome Ranking for the Management of Antimicrobial Therapy (DOOR MAT): A Framework for Assessing Antibiotic Selection Strategies in the Presence of Drug Resistance. Clin Infect Dis 2021; 73:344-350. [PMID: 33245333 DOI: 10.1093/cid/ciaa1769] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 11/23/2020] [Indexed: 11/12/2022] Open
Abstract
The complexities of antibiotic resistance mean that successful stewardship must consider both the effectiveness of a given antibiotic and the spectrum of that therapy to minimize imposing further selective pressure. To meet this challenge, we propose the Desirability of Outcome Ranking approach for the Management of Antimicrobial Therapy (DOOR MAT), a flexible quantitative framework that evaluates the desirability of antibiotic selection. Herein, we describe the steps required to implement DOOR MAT and present examples to illustrate how the desirability of treatment selection can be evaluated using resistance information. While treatments and the scoring of treatment selections must be adapted to specific clinical settings, the principle of DOOR MAT remains constant: The most desirable antibiotic choice effectively treats the patient while exerting minimal pressure on future resistance.
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Affiliation(s)
- Brigid M Wilson
- Research Service, Veterans Affairs Northeast Ohio Healthcare System, Cleveland, Ohio, USA.,Geriatric Research Education and Clinical Center, Veterans Affairs Northeast Ohio Healthcare System, Cleveland, Ohio, USA.,Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Yunyun Jiang
- George Washington Biostatistics Center, George Washington University, Washington, District of Columbia, USA
| | - Robin L P Jump
- Geriatric Research Education and Clinical Center, Veterans Affairs Northeast Ohio Healthcare System, Cleveland, Ohio, USA.,Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Medical Service, Veterans Affairs Northeast Ohio Healthcare System, Cleveland, USA.,Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | | | - Federico Perez
- Geriatric Research Education and Clinical Center, Veterans Affairs Northeast Ohio Healthcare System, Cleveland, Ohio, USA.,Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Medical Service, Veterans Affairs Northeast Ohio Healthcare System, Cleveland, USA
| | - Robert A Bonomo
- Departments of Pharmacology, Molecular Biology and Microbiology, Biochemistry, and Proteomics and Bioinformatics, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Center for Antimicrobial Resistance and Epidemiology, Case Western Reserve University-Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA
| | - Scott R Evans
- George Washington Biostatistics Center, George Washington University, Washington, District of Columbia, USA
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30
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Alhmidi H, Cadnum JL, Koganti S, Jencson AL, Wilson BM, Donskey CJ. Shedding of methicillin-resistant Staphylococcus aureus and multidrug-resistant gram-negative bacilli during outpatient appointments and procedures outside hospital rooms. Am J Infect Control 2021; 49:991-994. [PMID: 33713732 DOI: 10.1016/j.ajic.2021.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/03/2021] [Accepted: 03/03/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Limited information is available on the frequency of and risk factors for shedding of health care-associated pathogens in settings outside patient rooms. METHODS We conducted a cohort study of hospitalized or recently discharged patients with methicillin-resistant Staphylococcus aureus (MRSA) (N = 39) or multidrug-resistant gram-negative bacilli (MDR-GNB) (N = 11) colonization to determine the frequency of environmental shedding during appointments outside hospital rooms or during outpatient clinic visits. Chi-square tests were performed to identify patient-level factors associated with environmental shedding. Spa typing was performed for environmental and nasal MRSA isolates. RESULTS Of 50 patients enrolled, 39 were colonized with MRSA and 11 with MDR-GNB. Shedding during 1 or more appointments occurred more often for patients colonized with MRSA versus MDR-GNB (15 of 39, 38.5% versus 0 of 11, 0%; P = .02). The presence of a wound with a positive culture for MRSA was associated with shedding of MRSA during appointments (11 of 15, 73.3% with shedding versus 4 of 24, 16.7% with no shedding; P = .008). Eighty percent of environmental MRSA isolates were genetically related to concurrent nasal isolates based on spa typing. CONCLUSIONS Environmental shedding of MRSA occurs frequently during appointments outside hospital rooms or during outpatient clinic visits. Decontamination of surfaces and strategies that reduce shedding of MRSA could reduce the risk for transmission in these settings.
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Perez F, Colindres RV, Wilson BM, Saade E, Jump RLP, Banerjee R, Patel R, Evans SR, Bonomo RA. The Desirability of Outcome Ranking for the Management of Antimicrobial Therapy (DOOR MAT) Reveals Improvements in the Treatment of Bloodstream Infection Caused by Escherichia coli and Klebsiella pneumoniae in Patients from the Veterans Health Administration. Clin Infect Dis 2021; 73:1231-1238. [PMID: 33978146 DOI: 10.1093/cid/ciab384] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Reductions in the use of broad-spectrum antibiotics is a cornerstone of antimicrobial stewardship. We aim to demonstrate the use of Desirability of Outcome Ranking Approach for the Management of Antimicrobial Therapy (DOOR MAT) to evaluate the treatment of Escherichia coli and Klebsiella pneumoniae bloodstream infection in patients from the Veterans Health Administration (VHA) across a decade. METHODS Using electronic records, we determined empiric and definitive antibiotic treatments, clinical characteristics and 30-day mortality of subjects with monomicrobial E. coli and K. pneumoniae bloodstream infection hospitalized in VHA medical centers from 2009 to 2018. Focusing on patients treated with parenteral β-lactams and with available antibiotic susceptibility testing results, we applied a range of DOOR MAT scores that reflect the desirability of antibiotic choices according to spectrum and activity against individual isolates. We report trends in resistance and desirability of empiric and definitive antibiotic treatments. RESULTS During the 10-year period analyzed, resistance to expanded-spectrum cephalosporins and fluoroquinolones increased in E. coli but not in K. pneumoniae, while resistance remained unchanged to carbapenems and piperacillin-tazobactam. In 6,451 cases analyzed, we observed improvements in DOOR MAT scores consistent with de-escalation. Improvement in desirability of definitive treatment compared to empiric treatment occurred in 26% of cases, increasing from 16% in 2009 to 34% in 2018. Reductions in overtreatment were sustained and without negative impact on survival. CONCLUSION DOOR MAT provides a framework to assess antibiotic treatment of E. coli and K. pneumoniae bloodstream infection and can be a useful metric in antimicrobial stewardship.
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Affiliation(s)
- Federico Perez
- Geriatric Research Education and Clinical Center, VA Northeast Ohio Healthcare System, Cleveland, USA.,Division of Infectious Diseases and HIV Medicine, Department of Medicine Case Western Reserve University (CWRU) School of Medicine, Cleveland, OH, USA
| | - Roberto Viau Colindres
- Division of Geographic Medicine and Infectious Diseases at Tufts Medical Center, Boston, MA, USA
| | - Brigid M Wilson
- Geriatric Research Education and Clinical Center, VA Northeast Ohio Healthcare System, Cleveland, USA.,Division of Infectious Diseases and HIV Medicine, Department of Medicine Case Western Reserve University (CWRU) School of Medicine, Cleveland, OH, USA
| | - Elie Saade
- Geriatric Research Education and Clinical Center, VA Northeast Ohio Healthcare System, Cleveland, USA.,Division of Infectious Diseases and HIV Medicine, Department of Medicine Case Western Reserve University (CWRU) School of Medicine, Cleveland, OH, USA
| | - Robin L P Jump
- Geriatric Research Education and Clinical Center, VA Northeast Ohio Healthcare System, Cleveland, USA.,Division of Infectious Diseases and HIV Medicine, Department of Medicine Case Western Reserve University (CWRU) School of Medicine, Cleveland, OH, USA.,Department of Population & Quantitative Health Sciences, CWRU School of Medicine, Cleveland, OH, USA
| | - Ritu Banerjee
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Robin Patel
- Division of Infectious Diseases and Division of Clinical Microbiology, Mayo Clinic, Rochester, MN, USA
| | - Scott R Evans
- George Washington Biostatistics Center, George Washington University, Washington, DC, USA
| | - Robert A Bonomo
- Geriatric Research Education and Clinical Center, VA Northeast Ohio Healthcare System, Cleveland, USA.,Division of Infectious Diseases and HIV Medicine, Department of Medicine Case Western Reserve University (CWRU) School of Medicine, Cleveland, OH, USA.,Departments of Pharmacology, Molecular Biology and Microbiology, Biochemistry, Proteomics and Bioinformatics, CWRU School of Medicine, Cleveland, OH, USA.,CWRU-Cleveland VAMC Center for Antimicrobial Resistance and Epidemiology (Case VA CARES), Cleveland, OH, USA
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Song S, Wilson BM, Marek J, Jump RLP. Use of electronic pharmacy transaction data and website development to assess antibiotic use in nursing homes. BMC Med Inform Decis Mak 2021; 21:148. [PMID: 33952239 PMCID: PMC8097250 DOI: 10.1186/s12911-021-01509-7] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 04/27/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In 2017, the Centers for Medicare and Medicaid Services required all long-term care facilities, including nursing homes, to have an antibiotic stewardship program. Many nursing homes lack the resources, expertise, or infrastructure to track and analyze antibiotic use measures. Here, we demonstrate that pharmacy invoices are a viable source of data to track and report antibiotic use in nursing homes. METHODS The dispensing pharmacy working with several nursing homes in the same healthcare corporation provided pharmacy invoices from 2014 to 2016 as files formatted as comma separated values. We aggregated these files by aligning elements into a consistent set of variables and assessed the completeness of data from each nursing home over time. Data cleaning involved removing rows that did not describe systemic medications, de-duplication, consolidating prescription refills, and removing prescriptions for insulin and opioids, which are medications that were not administered at a regular dose or schedule. After merging this cleaned invoice data to nursing home census data including bed days of care and publicly available data characterizing bed allocation for each nursing home, we used the resulting database to describe several antibiotic use metrics and generated an interactive website to permit further analysis. RESULTS The resultant database permitted assessment of the following antibiotic use metrics: days of antibiotic therapy, length of antibiotic therapy, rate of antibiotic starts, and the antibiotic spectrum index. Further, we created a template for summarizing data within a facility and comparing across facilities. https://sunahsong.shinyapps.io/USNursingHomes/ . CONCLUSIONS Lack of resources and infrastructure contributes to challenges facing nursing homes as they develop antibiotic stewardship programs. Our experience with using pharmacy invoice data may serve as a useful approach for nursing homes to track and report antibiotic use.
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Affiliation(s)
- Sunah Song
- Cleveland Institute for Computational Biology, Cleveland, OH, USA.,Department of Computer and Data Sciences, School of Engineering, Case Western Reserve University, Cleveland, OH, USA.,Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Brigid M Wilson
- Division of Infectious Diseases and HIV Medicine in the Department of Medicine, School of Medicine, Case Western Reserve University, Cleveland, OH, USA.,Geriatric Research Education and Clinical Center (GRECC), Veterans Affairs (VA) Northeast Ohio Healthcare System, 10701 East Blvd., Cleveland, OH, 44106, USA
| | - Joseph Marek
- CommuniCare Health Services, Cincinnati, OH, USA
| | - Robin L P Jump
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, OH, USA. .,Division of Infectious Diseases and HIV Medicine in the Department of Medicine, School of Medicine, Case Western Reserve University, Cleveland, OH, USA. .,Geriatric Research Education and Clinical Center (GRECC), Veterans Affairs (VA) Northeast Ohio Healthcare System, 10701 East Blvd., Cleveland, OH, 44106, USA.
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Song S, Wilson BM, Bej T, Gravenstein S, Carter RR, Marek J, Jump RLP. Antibiotic Use Among Residents Receiving Skilled Nursing Care in 29 U.S. Nursing Homes. J Am Geriatr Soc 2020; 69:399-406. [PMID: 33037613 DOI: 10.1111/jgs.16856] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/31/2020] [Accepted: 09/10/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Data describing antibiotic use in U.S. nursing homes remain limited. We report antibiotic use among skilled nursing facility residents from 29 U.S. nursing homes and assessed correlations between antibiotics prescribed to residents in skilled care and nursing home characteristics. DESIGN Retrospective cohort study. SETTING Twenty-nine U.S. nursing homes in the same healthcare corporation. PARTICIPANTS Residents receiving skilled care in 2016. MEASUREMENTS We used pharmacy invoice and nursing home census data to calculate the days of antibiotic therapy per 1,000 days of skilled care (1,000 DOSC), the rate of antibiotic starts per 1,000 DOSC, the length of antibiotic therapy, and the average antibiotic spectrum index. We also assessed correlations between antibiotic use and nursing home characteristics. RESULTS Antibiotics accounted for an average of 9.6% (±0.6%) of systemic medications prescribed among residents receiving skilled care. On average, 26.8% (±2.9%) of antibiotics were intravenous. Fluoroquinolones were prescribed at the highest rates (19% across all facilities), followed by beta-lactam/beta-lactamase inhibitors (11%), first- and second-generation cephalosporins, sulfonamides, and oral tetracyclines (each at 9%). Both the proportion of residents using enrolled in Medicare and number of unique prescribers responsible for systemic prescriptions positively correlated with the rate of antibiotic starts. CONCLUSIONS Our study demonstrates that pharmacy invoices represent a useful and preexisting source of data for assessing antibiotic prescriptions among individuals receiving skilled nursing care. The correlation between the number of unique prescribers and antibiotic starts suggests that prescribers are central to efforts to improve antibiotic use in nursing homes.
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Affiliation(s)
- Sunah Song
- Cleveland Institute for Computational Biology, Cleveland, Ohio, USA.,Department of Computer and Data Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Brigid M Wilson
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Geriatric Research Education and Clinical Center (GRECC) at the VA Northeast Ohio Healthcare System, Cleveland, Ohio, USA
| | - Taissa Bej
- Geriatric Research Education and Clinical Center (GRECC) at the VA Northeast Ohio Healthcare System, Cleveland, Ohio, USA
| | - Stefan Gravenstein
- Brown University Alpert Medical School and School of Public Health, Brown University, Providence, Rhode Island, USA.,Providence VA Medical Center, Providence, Rhode Island, USA
| | - Rebecca R Carter
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Center for the Advancement of Team Science, Analytics, and Systems Thinking, Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Joseph Marek
- CommuniCare Health Services, Cincinnati, Ohio, USA
| | - Robin L P Jump
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Division of Infectious Diseases & HIV Medicine, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Geriatric Research Education and Clinical Center (GRECC) at the VA Northeast Ohio Healthcare System, Cleveland, Ohio, USA
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Maji D, Opneja A, Suster MA, Bane KL, Wilson BM, Mohseni P, Stavrou EX. Monitoring DOACs with a Novel Dielectric Microsensor: A Clinical Study. Thromb Haemost 2020; 121:58-69. [PMID: 32877954 DOI: 10.1055/s-0040-1715589] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND There are acute settings where assessing the anticoagulant effect of direct oral anticoagulants (DOACs) can be useful. Due to variability among routine coagulation tests, there is an unmet need for an assay that detects DOAC effects within minutes in the laboratory or at the point of care. METHODS We developed a novel dielectric microsensor, termed ClotChip, and previously showed that the time to reach peak permittivity (T peak) is a sensitive parameter of coagulation function. We conducted a prospective, single-center, pilot study to determine its clinical utility at detecting DOAC anticoagulant effects in whole blood. RESULTS We accrued 154 individuals: 50 healthy volunteers, 49 rivaroxaban patients, 47 apixaban, and 8 dabigatran patients. Blood samples underwent ClotChip measurements and plasma coagulation tests. Control mean T peak was 428 seconds (95% confidence interval [CI]: 401-455 seconds). For rivaroxaban, mean T peak was 592 seconds (95% CI: 550-634 seconds). A receiver operating characteristic curve showed that the area under the curve (AUC) predicting rivaroxaban using T peak was 0.83 (95% CI: 0.75-0.91, p < 0.01). For apixaban, mean T peak was 594 seconds (95% CI: 548-639 seconds); AUC was 0.82 (95% CI: 0.73-0.91, p < 0.01). For dabigatran, mean T peak was 894 seconds (95% CI: 701-1,086 seconds); AUC was 1 (p < 0.01). Specificity for all DOACs was 88%; sensitivity ranged from 72 to 100%. CONCLUSION This diagnostic study using samples from "real-world" DOAC patients supports that ClotChip exhibits high sensitivity at detecting DOAC anticoagulant effects in a disposable portable platform, using a miniscule amount of whole blood (<10 µL).
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Affiliation(s)
- Debnath Maji
- Department of Electrical, Computer, and Systems Engineering, Case Western Reserve University, Cleveland, Ohio, United States
| | - Aman Opneja
- Hematology and Oncology Division, Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, United States.,Division of Hematology-Oncology, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States
| | - Michael A Suster
- Department of Electrical, Computer, and Systems Engineering, Case Western Reserve University, Cleveland, Ohio, United States
| | - Kara L Bane
- Division of Hematology-Oncology, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States
| | - Brigid M Wilson
- Geriatric Research Education and Clinical Center, Louis Stokes Cleveland Veterans Administration Medical Center, VA Northeast Ohio Healthcare System, Cleveland, Ohio, United States.,Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States
| | - Pedram Mohseni
- Department of Electrical, Computer, and Systems Engineering, Case Western Reserve University, Cleveland, Ohio, United States
| | - Evi X Stavrou
- Division of Hematology-Oncology, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States.,Section of Hematology-Oncology, Department of Medicine, Louis Stokes Cleveland Veterans Administration Medical Center, VA Northeast Ohio Healthcare System, Cleveland, Ohio, United States
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Wilson BM, Perez F, Pan Q, Jiang Y, Evans SR, Bonomo RA. Acinetobacter Infections. Clin Infect Dis 2020; 71:1357-1358. [PMID: 31734703 DOI: 10.1093/cid/ciz1099] [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] [Indexed: 11/14/2022] Open
Affiliation(s)
- Brigid M Wilson
- Research Services, Veterans Affairs Northeast Ohio Healthcare System and Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA.,Veterans Affairs Northeast Ohio Healthcare System, Cleveland, Ohio, USA.,Geriatrics Research, Education and Clinical Center, Veterans Affairs Northeast Ohio Healthcare System and Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA
| | - Federico Perez
- Research Services, Veterans Affairs Northeast Ohio Healthcare System and Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA.,Veterans Affairs Northeast Ohio Healthcare System, Cleveland, Ohio, USA.,Geriatrics Research, Education and Clinical Center, Veterans Affairs Northeast Ohio Healthcare System and Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA.,Medicine, Veterans Affairs Northeast Ohio Healthcare System and Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA
| | - Qing Pan
- George Washington Biostatistics Center, George Washington University, Washington, District of Columbia, USA
| | - Yunyun Jiang
- George Washington Biostatistics Center, George Washington University, Washington, District of Columbia, USA
| | - Scott R Evans
- George Washington Biostatistics Center, George Washington University, Washington, District of Columbia, USA
| | - Robert A Bonomo
- Research Services, Veterans Affairs Northeast Ohio Healthcare System and Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA.,Veterans Affairs Northeast Ohio Healthcare System, Cleveland, Ohio, USA.,Geriatrics Research, Education and Clinical Center, Veterans Affairs Northeast Ohio Healthcare System and Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA.,Medicine, Veterans Affairs Northeast Ohio Healthcare System and Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA.,Center for Antimicrobial Resistance and Epidemiology, Case Western Reserve University-Cleveland Veterans Affairs Medical Center (Case VA CARES), Cleveland, Ohio, USA.,Departments of Medicine, Pharmacology, Biochemistry, Molecular Biology & Microbiology, and Proteomics & Bioinformatics, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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36
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Evans SR, Tran TTT, Hujer AM, Hill CB, Hujer KM, Mediavilla JR, Manca C, Domitrovic TN, Perez F, Farmer M, Pitzer KM, Wilson BM, Kreiswirth BN, Patel R, Jacobs MR, Chen L, Fowler VG, Chambers HF, Bonomo RA. Rapid Molecular Diagnostics to Inform Empiric Use of Ceftazidime/Avibactam and Ceftolozane/Tazobactam Against Pseudomonas aeruginosa: PRIMERS IV. Clin Infect Dis 2020; 68:1823-1830. [PMID: 30239599 DOI: 10.1093/cid/ciy801] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 09/18/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Overcoming β-lactam resistance in pathogens such as Pseudomonas aeruginosa is a major clinical challenge. Rapid molecular diagnostics (RMDs) have the potential to inform selection of empiric therapy in patients infected by P. aeruginosa. METHODS In this study, we used a heterogeneous collection of 197 P. aeruginosa that included multidrug-resistant isolates to determine whether 2 representative RMDs (Acuitas Resistome test and VERIGENE gram-negative blood culture test) could identify susceptibility to 2 newer β-lactam/β-lactamase inhibitor (BL-BLI) combinations, ceftazidime/avibactam (CZA) and ceftolozane/tazobactam (TOL/TAZO). RESULTS We found that the studied RMD platforms were able to correctly identify BL-BLI susceptibility (susceptibility sensitivity, 100%; 95% confidence interval [CI], 97%, 100%) for both BLs-BLIs. However, their ability to detect resistance to these BLs-BLIs was lower (resistance sensitivity, 66%; 95% CI, 52%, 78% for TOL/TAZO and 33%; 95% CI, 20%, 49% for CZA). CONCLUSIONS The diagnostic platforms studied showed the most potential in scenarios where a resistance gene was detected or in scenarios where a resistance gene was not detected and the prevalence of resistance to TOL/TAZO or CZA is known to be low. Clinicians need to be mindful of the benefits and risks that result from empiric treatment decisions that are based on resistance gene detection in P. aeruginosa, acknowledging that such decisions are impacted by the prevalence of resistance, which varies temporally and geographically.
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Affiliation(s)
- Scott R Evans
- The Biostatistics Center and the Department of Epidemiology and Biostatistics, George Washington University, Rockville, Maryland
| | - Thuy Tien T Tran
- The Biostatistics Center and the Department of Epidemiology and Biostatistics, George Washington University, Rockville, Maryland
| | - Andrea M Hujer
- Department of Medicine, Case Western Reserve University School of Medicine.,Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio
| | - Carol B Hill
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Kristine M Hujer
- Department of Medicine, Case Western Reserve University School of Medicine.,Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio
| | - Jose R Mediavilla
- Public Health Research Institute Center, New Jersey Medical School-Rutgers University, Newark
| | - Claudia Manca
- Public Health Research Institute Center, New Jersey Medical School-Rutgers University, Newark
| | - T Nicholas Domitrovic
- Department of Medicine, Case Western Reserve University School of Medicine.,Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio
| | - Federico Perez
- Department of Medicine, Case Western Reserve University School of Medicine.,Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio
| | | | | | - Brigid M Wilson
- Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio
| | - Barry N Kreiswirth
- Public Health Research Institute Center, New Jersey Medical School-Rutgers University, Newark
| | - Robin Patel
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Michael R Jacobs
- Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Liang Chen
- Public Health Research Institute Center, New Jersey Medical School-Rutgers University, Newark
| | - Vance G Fowler
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.,Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | | | - Robert A Bonomo
- Department of Medicine, Case Western Reserve University School of Medicine.,Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio.,Departments of Pharmacology, Molecular Biology and Microbiology, Biochemistry, and Proteomics and Bioinformatics, Case Western Reserve University School of Medicine.,CWRU-Cleveland VAMC Center for Antimicrobial Resistance and Epidemiology (Case VA CARES), Ohio
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Cadnum JL, Jencson AL, Livingston SH, Li DF, Redmond SN, Pearlmutter B, Wilson BM, Donskey CJ. Evaluation of an electrostatic spray disinfectant technology for rapid decontamination of portable equipment and large open areas in the era of SARS-CoV-2. Am J Infect Control 2020; 48:951-954. [PMID: 32522608 PMCID: PMC7275188 DOI: 10.1016/j.ajic.2020.06.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [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: 04/18/2020] [Revised: 06/01/2020] [Accepted: 06/02/2020] [Indexed: 11/16/2022]
Abstract
In the setting of the coronavirus disease 2019 pandemic, efficient methods are needed to decontaminate shared portable devices and large open areas such as waiting rooms. We found that wheelchairs, portable equipment, and waiting room chairs were frequently contaminated with potential pathogens. After minimal manual precleaning of areas with visible soiling, application of a dilute sodium hypochlorite disinfectant using an electrostatic sprayer provided rapid and effective decontamination and eliminated the benign virus bacteriophage MS2 from inoculated surfaces.
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Affiliation(s)
- Jennifer L Cadnum
- Research Service, Louis Stokes Cleveland VA Medical Center, Cleveland, OH
| | - Annette L Jencson
- Research Service, Louis Stokes Cleveland VA Medical Center, Cleveland, OH
| | | | - Daniel F Li
- Research Service, Louis Stokes Cleveland VA Medical Center, Cleveland, OH
| | - Sarah N Redmond
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Basya Pearlmutter
- Research Service, Louis Stokes Cleveland VA Medical Center, Cleveland, OH
| | - Brigid M Wilson
- Geriatric Research, Education, and Clinical Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH
| | - Curtis J Donskey
- Case Western Reserve University School of Medicine, Cleveland, OH; Geriatric Research, Education, and Clinical Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH.
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Papp-Wallace KM, Zeiser ET, Becka SA, Park S, Wilson BM, Winkler ML, D'Souza R, Singh I, Sutton G, Fouts DE, Chen L, Kreiswirth BN, Ellis-Grosse EJ, Drusano GL, Perlin DS, Bonomo RA. Ceftazidime-Avibactam in Combination With Fosfomycin: A Novel Therapeutic Strategy Against Multidrug-Resistant Pseudomonas aeruginosa. J Infect Dis 2020; 220:666-676. [PMID: 31099835 DOI: 10.1093/infdis/jiz149] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 04/12/2019] [Indexed: 02/06/2023] Open
Abstract
Previously, by targeting penicillin-binding protein 3, Pseudomonas-derived cephalosporinase (PDC), and MurA with ceftazidime-avibactam-fosfomycin, antimicrobial susceptibility was restored among multidrug-resistant (MDR) Pseudomonas aeruginosa. Herein, ceftazidime-avibactam-fosfomycin combination therapy against MDR P. aeruginosa clinical isolate CL232 was further evaluated. Checkerboard susceptibility analysis revealed synergy between ceftazidime-avibactam and fosfomycin. Accordingly, the resistance elements present and expressed in P. aeruginosa were analyzed using whole-genome sequencing and transcriptome profiling. Mutations in genes that are known to contribute to β-lactam resistance were identified. Moreover, expression of blaPDC, the mexAB-oprM efflux pump, and murA were upregulated. When fosfomycin was administered alone, the frequency of mutations conferring resistance was high; however, coadministration of fosfomycin with ceftazidime-avibactam yielded a lower frequency of resistance mutations. In a murine infection model using a high bacterial burden, ceftazidime-avibactam-fosfomycin significantly reduced the P. aeruginosa colony-forming units (CFUs), by approximately 2 and 5 logs, compared with stasis and in the vehicle-treated control, respectively. Administration of ceftazidime-avibactam and fosfomycin separately significantly increased CFUs, by approximately 3 logs and 1 log, respectively, compared with the number at stasis, and only reduced CFUs by approximately 1 log and 2 logs, respectively, compared with the number in the vehicle-treated control. Thus, the combination of ceftazidime-avibactam-fosfomycin was superior to either drug alone. By employing a "mechanism-based approach" to combination chemotherapy, we show that ceftazidime-avibactam-fosfomycin has the potential to offer infected patients with high bacterial burdens a therapeutic hope against infection with MDR P. aeruginosa that lack metallo-β-lactamases.
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Affiliation(s)
- Krisztina M Papp-Wallace
- Research Service, Louis Stokes Cleveland VA Medical Center.,Department of Medicine, Case Western Reserve University (CWRU), Cleveland, Ohio.,Department of Biochemistry, Case Western Reserve University (CWRU), Cleveland, Ohio.,Center for Proteomics and Bioinformatics, Case Western Reserve University (CWRU), Cleveland, Ohio
| | - Elise T Zeiser
- Research Service, Louis Stokes Cleveland VA Medical Center
| | - Scott A Becka
- Research Service, Louis Stokes Cleveland VA Medical Center
| | - Steven Park
- Hackensack Meridian Health Center for Discovery and Innovation, Nutley, New Jersey
| | - Brigid M Wilson
- Research Service, Louis Stokes Cleveland VA Medical Center.,Geriatric Research Education and Clinical Center, Louis Stokes Cleveland VA Medical Center.,Department of Medicine, Case Western Reserve University (CWRU), Cleveland, Ohio
| | | | | | | | | | | | - Liang Chen
- Hackensack Meridian Health Center for Discovery and Innovation, Nutley, New Jersey
| | - Barry N Kreiswirth
- Hackensack Meridian Health Center for Discovery and Innovation, Nutley, New Jersey
| | | | - George L Drusano
- Institute for Therapeutic Innovation, University of Florida, Orlando
| | - David S Perlin
- Hackensack Meridian Health Center for Discovery and Innovation, Nutley, New Jersey
| | - Robert A Bonomo
- Research Service, Louis Stokes Cleveland VA Medical Center.,Medical Service, Louis Stokes Cleveland VA Medical Center.,Geriatric Research Education and Clinical Center, Louis Stokes Cleveland VA Medical Center.,Department of Medicine, Case Western Reserve University (CWRU), Cleveland, Ohio.,Department of Biochemistry, Case Western Reserve University (CWRU), Cleveland, Ohio.,Center for Proteomics and Bioinformatics, Case Western Reserve University (CWRU), Cleveland, Ohio.,Department of Molecular Biology and Microbiology, Case Western Reserve University (CWRU), Cleveland, Ohio.,Department of Pharmacology, Case Western Reserve University (CWRU), Cleveland, Ohio.,CWRU-Cleveland VAMC Center for Antimicrobial Resistance and Epidemiology, Cleveland, Ohio
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Cadnum JL, Li DF, Jones LD, Redmond SN, Pearlmutter B, Wilson BM, Donskey CJ. Evaluation of Ultraviolet-C Light for Rapid Decontamination of Airport Security Bins in the Era of SARS-CoV-2. Pathog Immun 2020; 5:133-142. [PMID: 32582873 PMCID: PMC7307442 DOI: 10.20411/pai.v5i1.373] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [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: 04/08/2020] [Accepted: 05/15/2020] [Indexed: 12/12/2022] Open
Abstract
Background: Contaminated surfaces are a potential source for spread of respiratory viruses including SARS-CoV-2. Ultraviolet-C (UV-C) light is effective against RNA and DNA viruses and could be useful for decontamination of high-touch fomites that are shared by multiple users. Methods: A modification of the American Society for Testing and Materials standard quantitative carrier disk test method (ASTM E-2197-11) was used to examine the effectiveness of UV-C light for rapid decontamination of plastic airport security bins inoculated at 3 sites with methicillin-resistant Staphylococcus aureus (MRSA) and bacteriophages MS2, PhiX174, and Phi6, an enveloped RNA virus used as a surrogate for coronaviruses. Reductions of 3 log10 on inoculated plastic bins were considered effective for decontamination. Results: UV-C light administered as 10-, 20-, or 30-second cycles in proximity to a plastic bin reduced contamination on each of the test sites, including vertical and horizontal surfaces. The 30-second cycle met criteria for decontamination of all 3 test sites for all the test organisms except bacteriophage MS2 which was reduced by greater than 2 log10 PFU at each site. Conclusions: UV-C light is an attractive technology for rapid decontamination of airport security bins. Further work is needed to evaluate the utility of UV-C light in real-world settings and to develop methods to provide automated movement of bins through a UV-C decontamination process.
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Affiliation(s)
- Jennifer L Cadnum
- Research Service; Louis Stokes Cleveland VA Medical Center; Cleveland, Ohio
| | - Daniel F Li
- Research Service; Louis Stokes Cleveland VA Medical Center; Cleveland, Ohio
| | - Lucas D Jones
- Department of Molecular Biology and Microbiology; Case Western Reserve University School of Medicine; Cleveland Ohio
| | - Sarah N Redmond
- Case Western Reserve University School of Medicine; Cleveland, Ohio
| | - Basya Pearlmutter
- Research Service; Louis Stokes Cleveland VA Medical Center; Cleveland, Ohio
| | - Brigid M Wilson
- Geriatric Research, Education, and Clinical Center; Louis Stokes Cleveland VA Medical Center; Cleveland, Ohio
| | - Curtis J Donskey
- Case Western Reserve University School of Medicine; Cleveland, Ohio.,Geriatric Research, Education, and Clinical Center; Louis Stokes Cleveland VA Medical Center; Cleveland, Ohio
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Wojnarski CM, Elgudin Y, Rubelowsky JJ, Wilson BM, Donskey CJ, Cmolik BL. Emerging trends in mediastinitis: National Veterans Health Administration experience with methicillin-resistant Staphylococcus aureus prevention. J Thorac Cardiovasc Surg 2020; 162:1125-1130.e1. [PMID: 32386766 DOI: 10.1016/j.jtcvs.2020.02.116] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 10/29/2018] [Revised: 02/25/2020] [Accepted: 02/26/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Perioperative bacterial decolonization and prophylactic antibiotic therapy at the Veterans Affairs Health Care System have changed over the past decade. Our objectives were to identify associated changes in the microbiology of mediastinitis and to perform a contemporary survival analysis in patients with mediastinitis after isolated coronary artery bypass grafting procedure. METHODS From January 2006 to December 2015, 45,323 consecutive patients underwent coronary artery bypass grafting at 83 medical centers. The Veterans Affairs Health Care System nationwide administrative database was queried to identify patients with postoperative mediastinitis and obtain patient-level data. Simple descriptive statistics and multivariable logistic regression were used to analyze microbiologic data and identify risk factors for infection. Poisson regression was used to determine yearly incidence estimates. Cox proportional hazard model identified predictors of long-term survival from date of operation. RESULTS During the study period, 348 patients (0.78%) developed postoperative mediastinitis-with a stable rate of incidence (Cochrane-Armitage test, P = .69). Of patients with microbiologic data, 75.5% of infections (n = 188) were caused by gram-positive and 24.5% (n = 61) gram-negative organisms. The incidence of methicillin-resistant Staphylococcus aureus mediastinitis decreased during the study period (Cochrane-Armitage test, P = .013). Gram-negative mediastinitis occurred earlier than gram-positive mediastinitis (median, 15.0 vs 25.0 days; P < .0001). Patients with mediastinitis did not have increased 30-day mortality (2.0% vs 1.9%; P = .9), but had worse long-term survival compared with uninfected patients (P < .0001). CONCLUSIONS The incidence of methicillin-resistant S aureus mediastinitis has decreased over the past decade. Gram-negative bacteria are responsible for 1 in 4 cases of mediastinitis and infection is diagnosed earlier in the postoperative period than gram-positive mediastinitis. These findings highlight the need for efforts to prevent gram-negative and methicillin-susceptible S aureus mediastinitis.
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Affiliation(s)
- Charles M Wojnarski
- Department of Cardiothoracic Surgery, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio; Department of Thoracic and Cardiovascular Surgery, Duke University Medical Center, Durham, NC.
| | - Yakov Elgudin
- Department of Cardiothoracic Surgery, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio
| | - Joseph J Rubelowsky
- Department of Cardiothoracic Surgery, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio
| | - Brigid M Wilson
- Geriatric Research, Education and Clinical Center, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio
| | - Curtis J Donskey
- Geriatric Research, Education and Clinical Center, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio; Infectious Diseases Section, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio
| | - Brian L Cmolik
- Department of Cardiothoracic Surgery, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio
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Jump RLP, Wilson BM, Baechle D, Briggs JM, Banks RE, Song S, Zappernick T, Perez F. Risk Factors and Mortality Rates Associated With Invasive Group B Streptococcus Infections Among Patients in the US Veterans Health Administration. JAMA Netw Open 2019; 2:e1918324. [PMID: 31880800 PMCID: PMC6991221 DOI: 10.1001/jamanetworkopen.2019.18324] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
IMPORTANCE The incidence of invasive infections caused by group B Streptococcus (GBS) continues to increase in the United States. Although diabetes is a key risk factor for invasive GBS, the influence of long-term glycemic control is not well characterized; other risk factors and mortality rates associated with specific types of invasive GBS infections are unknown. OBJECTIVE To investigate risk factors and mortality rates associated with specific invasive GBS infectious syndromes. DESIGN, SETTING, AND PARTICIPANTS This cohort study used US Veterans Health Administration data to assess active users of the Veterans Affairs health care system between January 1, 2008, and December 31, 2017. Data analysis was conducted from April 2018 to August 2019. EXPOSURES Invasive GBS infections. MAIN OUTCOMES AND MEASURES The specific types of infectious syndromes and comorbid conditions among patients with an invasive GBS infection were evaluated. RESULTS Between 2008 and 2017, 5175 patients in the Veterans Affairs health care system experienced 5497 invasive GBS infections (5027 [97.1%] men, 3737 [72.2%] white, and 4545 [87.8%] non-Latino); all-cause 30-day mortality was 8.7% (451 of 5175). The most frequently observed infections were osteomyelitis (1171 [21.3%]), bacteremia without focus (1009 [18.4%]), skin or soft-tissue infections (919 [16.7%]), and pneumonia or empyema (694 [12.6%]). All-cause 30-day mortality following the index infection for each patient was highest among patients with peritonitis (38 of 138 [27.5%]) and pneumonia or empyema (116 of 664 [17.5%]) and lowest among those with osteomyelitis (15 of 1075 [1.4%]) or joint infection (17 of 501 [3.4%]). The most common comorbid conditions among patients with invasive GBS infections were diabetes (3364 [65.0%]), obesity (2669 [51.6%]), and chronic heart conditions (1633 [31.6%]). From 2008 to 2017, the incidence of invasive GBS infections increased from 9.23 to 11.67 cases per 100 000 person-years (P = .049). Stratification by body mass index showed the highest incidence of infections among patients at the extremes of body mass index (body mass index <18.5, 25.1 cases per 100 000 person-years; body mass index ≥40, 31.0 cases per 100 000 person-years). The incidence among patients with diabetes and poor long-term glycemic control (ie, hemoglobin A1c ≥9.5%) was 4-fold greater than among patients with diabetes and good glycemic control (ie, hemoglobin A1c <7.5%) (78.3 cases vs 19.0 cases per 100 000 person-years; unadjusted incident rate ratio, 4.1; 95% CI, 3.7-4.4; P < .001). CONCLUSIONS AND RELEVANCE In this cohort study, comorbid conditions and 30-day mortality varied among types of invasive GBS infections. Obesity and poor long-term glycemic control were associated with invasive GBS infections. Efforts to reverse the trend of an increased incidence of invasive GBS infections should continue to support reducing obesity and focus on improving glycemic control.
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Affiliation(s)
- Robin L. P. Jump
- Geriatric Research Education and Clinical Center, VA Northeast Ohio Healthcare System, Cleveland
- Specialty Care Center of Innovation, VA Northeast Ohio Healthcare System, Cleveland
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Brigid M. Wilson
- Geriatric Research Education and Clinical Center, VA Northeast Ohio Healthcare System, Cleveland
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Daniel Baechle
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Cleveland Institute for Computational Biology, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Janet M. Briggs
- Geriatric Research Education and Clinical Center, VA Northeast Ohio Healthcare System, Cleveland
| | - Richard E. Banks
- Geriatric Research Education and Clinical Center, VA Northeast Ohio Healthcare System, Cleveland
| | - Sunah Song
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Cleveland Institute for Computational Biology, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Taissa Zappernick
- Geriatric Research Education and Clinical Center, VA Northeast Ohio Healthcare System, Cleveland
| | - Federico Perez
- Geriatric Research Education and Clinical Center, VA Northeast Ohio Healthcare System, Cleveland
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
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Jones LD, Mana TS, Cadnum JL, Jencson AL, Alhmidi H, Silva SY, Wilson BM, Donskey CJ. Instillation of disinfectant behind a temporary obstruction created by an inflated urinary catheter balloon improves sink drain disinfection. Am J Infect Control 2019; 47:1522-1524. [PMID: 31402067 DOI: 10.1016/j.ajic.2019.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 07/12/2019] [Indexed: 10/26/2022]
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Wilson BM, Bessesen MT, Doros G, Brown ST, Saade E, Hermos J, Perez F, Skalweit M, Spellberg B, Bonomo RA. Adjunctive Rifampin Therapy For Diabetic Foot Osteomyelitis in the Veterans Health Administration. JAMA Netw Open 2019; 2:e1916003. [PMID: 31755948 PMCID: PMC6902814 DOI: 10.1001/jamanetworkopen.2019.16003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [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: 12/19/2022] Open
Abstract
IMPORTANCE Among patients diagnosed with diabetes, the lifetime incidence of foot ulcers is 15%. Infection is a common complication of foot ulcers, and 20% to 60% of infections result in diabetic foot osteomyelitis (DFO). Current treatment guidelines do not endorse any specific antibiotic agent for DFO, but small clinical trials suggest the addition of rifampin to antimicrobial regimens results in improved cure rates for osteomyelitis. OBJECTIVE To compare the clinical outcomes of patients treated for DFO in the Veterans Health Administration (VHA) with and without adjunctive rifampin. DESIGN, SETTING, AND PARTICIPANTS This observational cohort study used VHA databases to identify index DFO cases from January 1, 2009, through December 31, 2013, and analyzed patients alive and without high-level amputation at 90 days after diagnosis in whom antibiotic therapy was initiated within 6 weeks of diagnosis. Patients with death or major amputation within 90 days of diagnosis, who were not treated with systemic antibiotics dispensed by the VHA within 6 weeks of diagnosis, or who were treated at facilities where rifampin was not dispensed for DFO were excluded. The retrospective cohort to inform the planning of a multisite randomized clinical trial was first investigated in spring 2015; retrospective analysis was performed from February 2017 through September 2019. EXPOSURES Patients initiating rifampin therapy within 6 weeks of the DFO diagnosis and receiving the drug for at least 14 days within 90 days of diagnosis were considered treated with rifampin. Patients not administered rifampin within 90 days of diagnosis served as the comparator group. MAIN OUTCOMES AND MEASURES A combined end point of mortality or amputation within 2 years of diagnosis was analyzed. Differences in times to event were evaluated using log-rank tests. Differences in event rates were compared using χ2 tests and multivariable logistic regression. RESULTS The analysis population included 130 patients treated with rifampin and 6044 treated without rifampin (total of 6174; 6085 men [98.6%]; mean [SD] age, 64.9 [9.7] years). Lower event rates were observed among the rifampin group (35 of 130 [26.9%] vs 2250 of 6044 [37.2%]; P = .02). Patients treated with rifampin were younger (mean [SD] age, 62.2 [9.4] vs 64.9 [9.6] years), had fewer comorbidities (mean [SD] Charlson comorbidity index score, 3.5 [1.8] vs 4.0 [2.2]), had more infectious disease specialty consultations (63 of 130 [48.5%] vs 1960 of 6044 [32.4%]), and more often had Staphylococcus aureus identified in cultures (55 of 130 [42.3%] vs 1755 of 6044 [29.0%]) than patients not treated with rifampin. A logistic regression estimating the odds of events and controlling for these and other covariates yielded a significant association of rifampin (odds ratio, 0.65; 95% CI, 0.43-0.96; P = .04). CONCLUSIONS AND RELEVANCE In this cohort study, patients administered rifampin experienced lower rates of death and amputation than patients not treated with rifampin, which remained significant after adjustment for confounders. These results coupled with existing evidence from small clinical trials suggest the addition of rifampin to current treatment regimens may be a useful antimicrobial option in the treatment of DFO.
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Affiliation(s)
- Brigid M. Wilson
- Research Service and Geriatric Research, Education, and Clinical Center (GRECC),VA Northeast Ohio Healthcare System, Cleveland
- Division of Infectious Diseases, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Mary T. Bessesen
- Division of Infectious Diseases, University of Colorado, Denver, School of Medicine, Department of Veterans Affairs Eastern Colorado Healthcare System, Aurora
| | - Gheorghe Doros
- Massachusetts Veterans Epidemiology Research and Information Center, Boston
- Boston University School of Medicine, Boston, Massachusetts
| | - Sheldon T. Brown
- James J. Peters Veterans Affairs Medical Center, Bronx, New York
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Elie Saade
- Division of Infectious Diseases, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Research Service, VA Northeast Ohio Healthcare System, Cleveland
- University Hospitals of Cleveland, Cleveland, Ohio
| | - John Hermos
- Massachusetts Veterans Epidemiology Research and Information Center, Boston
- Veterans Affairs Boston Healthcare System, Boston, Massachusetts
- Department of General Internal Medicine, Boston University, Boston, Massachusetts
| | - Federico Perez
- Division of Infectious Diseases, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Medicine Service and GRECC, VA Northeast Ohio Healthcare System, Cleveland
| | - Marion Skalweit
- Medicine Service and GRECC, VA Northeast Ohio Healthcare System, Cleveland
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Department of Biochemistry, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Brad Spellberg
- Los Angeles County and University of Southern California Medical Center, Los Angeles
- Department of Medicine, Keck School of Medicine of University of Southern California, Los Angeles
| | - Robert A. Bonomo
- Medicine Service and GRECC, VA Northeast Ohio Healthcare System, Cleveland
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Department of Biochemistry, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Department of Pharmacology, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Department of Molecular Biology and Microbiology, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Department of Proteomics and Bioinformatics, Case Western Reserve University School of Medicine, Cleveland, Ohio
- CWRU (Case Western Reserve University)–Cleveland VAMC Center for Antimicrobial Resistance and Epidemiology, Cleveland, Ohio
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Redmond SN, Silva SY, Wilson BM, Cadnum JL, Donskey CJ. Impact of Reduced Fluoroquinolone Use on Clostridioides difficile Infections Resulting From the Fluoroquinolone-Resistant Ribotype 027 Strain in a Veterans Affairs Medical Center. Pathog Immun 2019; 4:251-259. [PMID: 31637329 PMCID: PMC6782113 DOI: 10.20411/pai.v4i2.327] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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: 08/16/2019] [Accepted: 09/23/2019] [Indexed: 12/18/2022] Open
Abstract
Background Fluoroquinolone restriction has been proposed as a control measure for Clostridioides difficile infection (CDI) outbreaks associated with fluoroquinolone-resistant ribotype 027 strains. However, relatively few reports of fluoroquinolone restriction interventions have evaluated the impact on C. difficile strain types and fluoroquinolone resistance. Methods In a hospital and affiliated long-term care facility (LTCF), antimicrobial stewardship and environmental cleaning interventions were implemented between 2009 and 2018, and C. difficile isolates during this period (~20 per year) were ribotyped and tested for fluoroquinolone resistance by moxifloxacin minimum inhibitory concentrations (MICs). Pearson's correlation coefficient was used to assess the association between use of fluoroquinolones and the percentage of CDI cases due to the 027 strain over time. Results Between 2009 and 2018, prescribing of fluoroquinolones to inpatients decreased by 43%, coinciding with significant reductions in the healthcare-associated CDI rates in the hospital and LTCF and a decline in the percentage of C. difficile isolates that were ribotype 027 from 70% to 10%. Ninety-five percent of ribotype 027 and 6% of non-027 isolates were moxifloxacin resistant. Hospital fluoroquinolone use was strongly correlated with the incidence of hospital-associated CDI (r = 0.79, 95% confidence interval, 0.31-0.95), but LTCF fluoroquinolone use was not correlated with LTCF-associated CDI (r = 0.29, 95% confidence interval, -0.43-0.77). During the study period, there were statistically significant downward trends in the use of penicillins, intravenous vancomycin, carbapenems, and clindamycin. Conclusion Our results provide support for fluoroquinolone restriction as a control measure for CDI outbreaks due to fluoroquinolone-resistant 027 strains, but also highlight the need for randomized trials as factors such as reduction in other antibiotic classes and improved cleaning may also impact CDI rates.
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Affiliation(s)
- Sarah N Redmond
- Case Western Reserve University School of Medicine; Cleveland, Ohio
| | - Sandra Y Silva
- Clinical and Translational Science Program; School of Medicine; Case Western Reserve University; Cleveland, Ohio
| | - Brigid M Wilson
- Geriatric Research, Education, and Clinical Center; Louis Stokes Cleveland VA Medical Center; Cleveland, Ohio
| | - Jennifer L Cadnum
- Research Service; Louis Stokes Cleveland VA Medical Center; Cleveland, Ohio
| | - Curtis J Donskey
- Case Western Reserve University School of Medicine; Cleveland, Ohio.,Geriatric Research, Education, and Clinical Center; Louis Stokes Cleveland VA Medical Center; Cleveland, Ohio
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Garner W, Wilson BM, Beste L, Maier M, Ohl ME, Van Epps P. Gaps in Preexposure Prophylaxis Uptake for HIV Prevention in the Veterans Health Administration. Am J Public Health 2019; 108:S305-S310. [PMID: 30383417 DOI: 10.2105/ajph.2018.304788] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To report demographics, regional variations, and indications for preexposure prophylaxis (PrEP) use for HIV prevention in the Veterans Health Administration (VHA). METHODS We identified persons initiating tenofovir/emtricitabine for the PrEP indication in the United States between July 2012 and April 2016 in a VHA national database. We stratified PrEP use by provider type and VHA region. We calculated PrEP initiation rate for each region with VHA population data. RESULTS Of the 825 persons who initiated PrEP during the observation period, 67% were White and 76% were men who have sex with men. People who inject drugs and transgender persons represented less than 1% each of the cohort. The majority of PrEP initiations were clustered in 3 states, leading with California (28%) followed by Florida (9%) and Texas (8%). The Southeast had one of the lowest PrEP rates at 10 PrEP initiations per 100 000 persons in care. Infectious disease specialists issued more than two thirds of index PrEP prescriptions. CONCLUSIONS Uptake of PrEP in the VHA is uneven along geographic and risk categories. Understanding the reasons behind these gaps will be key in expanding the use of this important prevention tool.
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Affiliation(s)
- Will Garner
- Will Garner is with University Hospitals Cleveland Medical Center, Cleveland, OH. Brigid M. Wilson is with Geriatric Research Education and Clinical Center, Research Service, Louis Stokes Cleveland VA Medical Center, and Case Western School of Medicine, Department of Medicine, Division of Infectious Diseases and HIV Medicine, Cleveland. Marissa Maier is with VA Portland Health Care System, and Department of Internal Medicine, Division of Infectious Diseases, Oregon Health and Sciences University, Portland. Lauren Beste is with VA Puget Sound Health Care System, and University of Washington School of Medicine, Department of Medicine, Division of General Internal Medicine, Seattle. Michael E. Ohl is with VHA Office of Rural Health Resource Center, and Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City. Puja Van Epps is with Geriatric Research Education and Clinical Center, Department of Medicine, Louis Stokes Cleveland VA Medical Center, and Case Western School of Medicine, Department of Medicine, Division of Infectious Diseases and HIV Medicine
| | - Brigid M Wilson
- Will Garner is with University Hospitals Cleveland Medical Center, Cleveland, OH. Brigid M. Wilson is with Geriatric Research Education and Clinical Center, Research Service, Louis Stokes Cleveland VA Medical Center, and Case Western School of Medicine, Department of Medicine, Division of Infectious Diseases and HIV Medicine, Cleveland. Marissa Maier is with VA Portland Health Care System, and Department of Internal Medicine, Division of Infectious Diseases, Oregon Health and Sciences University, Portland. Lauren Beste is with VA Puget Sound Health Care System, and University of Washington School of Medicine, Department of Medicine, Division of General Internal Medicine, Seattle. Michael E. Ohl is with VHA Office of Rural Health Resource Center, and Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City. Puja Van Epps is with Geriatric Research Education and Clinical Center, Department of Medicine, Louis Stokes Cleveland VA Medical Center, and Case Western School of Medicine, Department of Medicine, Division of Infectious Diseases and HIV Medicine
| | - Lauren Beste
- Will Garner is with University Hospitals Cleveland Medical Center, Cleveland, OH. Brigid M. Wilson is with Geriatric Research Education and Clinical Center, Research Service, Louis Stokes Cleveland VA Medical Center, and Case Western School of Medicine, Department of Medicine, Division of Infectious Diseases and HIV Medicine, Cleveland. Marissa Maier is with VA Portland Health Care System, and Department of Internal Medicine, Division of Infectious Diseases, Oregon Health and Sciences University, Portland. Lauren Beste is with VA Puget Sound Health Care System, and University of Washington School of Medicine, Department of Medicine, Division of General Internal Medicine, Seattle. Michael E. Ohl is with VHA Office of Rural Health Resource Center, and Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City. Puja Van Epps is with Geriatric Research Education and Clinical Center, Department of Medicine, Louis Stokes Cleveland VA Medical Center, and Case Western School of Medicine, Department of Medicine, Division of Infectious Diseases and HIV Medicine
| | - Marissa Maier
- Will Garner is with University Hospitals Cleveland Medical Center, Cleveland, OH. Brigid M. Wilson is with Geriatric Research Education and Clinical Center, Research Service, Louis Stokes Cleveland VA Medical Center, and Case Western School of Medicine, Department of Medicine, Division of Infectious Diseases and HIV Medicine, Cleveland. Marissa Maier is with VA Portland Health Care System, and Department of Internal Medicine, Division of Infectious Diseases, Oregon Health and Sciences University, Portland. Lauren Beste is with VA Puget Sound Health Care System, and University of Washington School of Medicine, Department of Medicine, Division of General Internal Medicine, Seattle. Michael E. Ohl is with VHA Office of Rural Health Resource Center, and Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City. Puja Van Epps is with Geriatric Research Education and Clinical Center, Department of Medicine, Louis Stokes Cleveland VA Medical Center, and Case Western School of Medicine, Department of Medicine, Division of Infectious Diseases and HIV Medicine
| | - Michael E Ohl
- Will Garner is with University Hospitals Cleveland Medical Center, Cleveland, OH. Brigid M. Wilson is with Geriatric Research Education and Clinical Center, Research Service, Louis Stokes Cleveland VA Medical Center, and Case Western School of Medicine, Department of Medicine, Division of Infectious Diseases and HIV Medicine, Cleveland. Marissa Maier is with VA Portland Health Care System, and Department of Internal Medicine, Division of Infectious Diseases, Oregon Health and Sciences University, Portland. Lauren Beste is with VA Puget Sound Health Care System, and University of Washington School of Medicine, Department of Medicine, Division of General Internal Medicine, Seattle. Michael E. Ohl is with VHA Office of Rural Health Resource Center, and Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City. Puja Van Epps is with Geriatric Research Education and Clinical Center, Department of Medicine, Louis Stokes Cleveland VA Medical Center, and Case Western School of Medicine, Department of Medicine, Division of Infectious Diseases and HIV Medicine
| | - Puja Van Epps
- Will Garner is with University Hospitals Cleveland Medical Center, Cleveland, OH. Brigid M. Wilson is with Geriatric Research Education and Clinical Center, Research Service, Louis Stokes Cleveland VA Medical Center, and Case Western School of Medicine, Department of Medicine, Division of Infectious Diseases and HIV Medicine, Cleveland. Marissa Maier is with VA Portland Health Care System, and Department of Internal Medicine, Division of Infectious Diseases, Oregon Health and Sciences University, Portland. Lauren Beste is with VA Puget Sound Health Care System, and University of Washington School of Medicine, Department of Medicine, Division of General Internal Medicine, Seattle. Michael E. Ohl is with VHA Office of Rural Health Resource Center, and Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City. Puja Van Epps is with Geriatric Research Education and Clinical Center, Department of Medicine, Louis Stokes Cleveland VA Medical Center, and Case Western School of Medicine, Department of Medicine, Division of Infectious Diseases and HIV Medicine
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Hecker MT, Son AH, Murphy NN, Sethi AK, Wilson BM, Watkins RR, Donskey CJ. Impact of syndrome-specific antimicrobial stewardship interventions on use of and resistance to fluoroquinolones: An interrupted time series analysis. Am J Infect Control 2019; 47:869-875. [PMID: 30850252 DOI: 10.1016/j.ajic.2019.01.026] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [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: 11/11/2018] [Revised: 01/28/2019] [Accepted: 01/28/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Fluoroquinolones are often prescribed unnecessarily and are an important risk factor for infection with fluoroquinolone-resistant gram-negative bacilli and Clostridioides difficile. METHODS We conducted a quasi-experimental study to determine the impact of sequential syndrome-specific stewardship interventions on use of and resistance to fluoroquinolones in a tertiary care hospital. An initial 2-year intervention focused on reducing treatment of asymptomatic bacteriuria and ensuring concordance of urinary tract infection treatment with guidelines. A second 5-year intervention focused on limiting overuse of fluoroquinolones for health care-associated pneumonia in conjunction with a formal stewardship program. The primary outcomes were fluoroquinolone use and changes in use over time analyzed by segmented regression analysis. RESULTS The asymptomatic bacteriuria and urinary tract infection intervention resulted in a significant reduction in fluoroquinolone use, with a significant change from an increasing to a decreasing rate of use (change in slope of quarterly defined daily doses/1,000 patient days -15.3, P < .01). The health care-associated pneumonia intervention resulted in a continued significant reduction in fluoroquinolone use (rate ratio = 0.68, P < .01). During the interventions, fluoroquinolone susceptibility increased significantly in Pseudomonas aeruginosa, but not in Escherichia coli, Klebsiella spp., or C difficile. CONCLUSIONS Antimicrobial stewardship interventions focused on specific syndromes may be effective in reducing fluoroquinolone use. In our hospital, reduction in fluoroquinolone use resulted in increased fluoroquinolone susceptibility in P aeruginosa, but not other Enterobacteriaceae or C difficile.
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Affiliation(s)
- Michelle T Hecker
- Division of Infectious Diseases, MetroHealth Medical Center, Cleveland, OH; Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Andrea H Son
- Department of Pharmacy, MetroHealth Medical Center, Cleveland, OH
| | | | - Ajay K Sethi
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Brigid M Wilson
- Geriatric Research, Education, and Clinical Center, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH
| | | | - Curtis J Donskey
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH; Geriatric Research, Education, and Clinical Center, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH.
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Alhmidi H, Gonzalez-Orta M, Cadnum JL, Mana TSC, Jencson AL, Wilson BM, Donskey CJ. Contamination of health care personnel during removal of contaminated gloves. Am J Infect Control 2019; 47:850-852. [PMID: 30638677 DOI: 10.1016/j.ajic.2018.12.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Revised: 11/30/2018] [Accepted: 12/01/2018] [Indexed: 11/29/2022]
Abstract
In simulations of contaminated glove removal, 37% of health care personnel using their typical doffing technique contaminated their skin with a fluorescent solution. The frequency of contamination was significantly lower when the technique recommended by the Centers for Disease Control and Prevention was used versus not used (8 of 34, 24% vs 29 of 66, 44%). In simulations in which only the palm of the glove was contaminated, a modified doffing technique, to minimize the risk for contact with contaminated surfaces, reduced contamination of personnel.
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Affiliation(s)
- Heba Alhmidi
- Research Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH
| | - Melany Gonzalez-Orta
- Research Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH; Department of Medicine, Cleveland Clinic Foundation, Cleveland, OH
| | - Jennifer L Cadnum
- Research Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH
| | - Thriveen S C Mana
- Research Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH
| | - Annette L Jencson
- Research Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH
| | - Brigid M Wilson
- Geriatric Research, Education, and Clinical Center, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH
| | - Curtis J Donskey
- Geriatric Research, Education, and Clinical Center, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH; Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH.
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Jencson AL, Cadnum JL, Wilson BM, Donskey CJ. Spores on wheels: Wheelchairs are a potential vector for dissemination ofpathogens in healthcare facilities. Am J Infect Control 2019; 47:459-461. [PMID: 30471969 DOI: 10.1016/j.ajic.2018.09.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 09/26/2018] [Accepted: 09/26/2018] [Indexed: 12/12/2022]
Abstract
In a hospital and affiliated long-term care facility, we found that shared wheelchairs were frequently contaminatedwith healthcare-associated pathogens, including Clostridium difficile spores. A network graph of 851 wheelchair transports over 3days demonstrated frequent movement between inpatient wards andoutpatient clinics, radiology, and physical therapy. These results highlight the potential for shared wheelchairs to serve as a vector for pathogen transmission.
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Affiliation(s)
- Annette L Jencson
- Research Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH
| | - Jennifer L Cadnum
- Research Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH
| | - Brigid M Wilson
- Geriatric Research, Education, and Clinical Center, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH; Case Western Reserve University School of Medicine, Cleveland, OH
| | - Curtis J Donskey
- Geriatric Research, Education, and Clinical Center, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH; Case Western Reserve University School of Medicine, Cleveland, OH.
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Burns CM, Banks RE, Wilson BM, Carter RR, Jump RLP, Perez F. A virtual clinic improves pneumococcal vaccination coverage among patients living with HIV at a Veterans Affairs Medical Center. AIDS Care 2017; 30:146-149. [PMID: 29052434 DOI: 10.1080/09540121.2017.1390542] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
People living with the human immunodeficiency virus (HIV) should receive pneumococcal vaccinations as part of their routine health maintenance. Our goal was to create a "virtual clinic" to help increase rates of pneumococcal vaccination among people living with HIV without adding substantially to the workload of primary providers. We used administrative data from our Veterans Affairs (VA) medical center to identify a cohort of veterans living with HIV who were not current with either the 13-valent pneumococcal conjugate vaccine (PCV13), the 23-valent pneumococcal polysaccharide vaccine (PPSV23) or both. We enrolled these individuals (n = 99) into a virtual clinic, notified providers via the electronic medical record and mailed letters to the veterans recommending they receive a pneumococcal vaccine. We also wrote orders for the appropriate pneumococcal vaccine that expired after 90 days. Among the virtual clinic cohort, 38% (38/99) of patients received the recommended vaccine within 180 days. Concurrent with our intervention, the Veterans Health Administration deployed a system-wide pneumococcal vaccine clinical reminder that incorporated recent PCV13 recommendations. To discern any effect of the virtual clinic beyond that of the clinical reminder, we compared the rate of PCV13 vaccinations among all HIV-positive veterans at our institution to the equivalent population from 2 other VA medical centers in Ohio. With consideration of the VHA's system-wide clinical reminder, the proportion of HIV-positive patients who received PCV13 in the first 90 days following the virtual clinic intervention was greater at our facility compared to another Ohio VA medical center (P < 0.05). The virtual clinic improved the pneumococcal vaccine coverage among HIV-positive veterans. These outcomes suggest that even in conjunction with a system-wide clinical reminder, the virtual clinic strategy improves vaccination rates among a high-risk population.
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Affiliation(s)
- Charles M Burns
- a Department of Medicine , University Hospitals Cleveland Medical Center , Cleveland , OH , USA
| | - Richard E Banks
- b Geriatric Research, Education and Clinical Center , Louis Stokes Cleveland Department of Veterans Affairs Medical Center (LSCVAMC) , Cleveland , OH , USA
| | - Brigid M Wilson
- b Geriatric Research, Education and Clinical Center , Louis Stokes Cleveland Department of Veterans Affairs Medical Center (LSCVAMC) , Cleveland , OH , USA
| | - Rebecca R Carter
- c Department of Epidemiology & Biostatistics , Case Western Reserve University School of Medicine , Cleveland , OH , USA
| | - Robin L P Jump
- b Geriatric Research, Education and Clinical Center , Louis Stokes Cleveland Department of Veterans Affairs Medical Center (LSCVAMC) , Cleveland , OH , USA.,c Department of Epidemiology & Biostatistics , Case Western Reserve University School of Medicine , Cleveland , OH , USA.,d Division of Infectious Diseases and HIV Medicine, Department of Medicine , Case Western Reserve University School of Medicine , Cleveland , OH , USA
| | - Federico Perez
- b Geriatric Research, Education and Clinical Center , Louis Stokes Cleveland Department of Veterans Affairs Medical Center (LSCVAMC) , Cleveland , OH , USA.,d Division of Infectious Diseases and HIV Medicine, Department of Medicine , Case Western Reserve University School of Medicine , Cleveland , OH , USA
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El Chakhtoura NG, Saade E, Wilson BM, Perez F, Papp-Wallace KM, Bonomo RA. A 17-Year Nationwide Study of Burkholderia cepacia Complex Bloodstream Infections Among Patients in the United States Veterans Health Administration. Clin Infect Dis 2017; 65:1253-1259. [PMID: 29017247 PMCID: PMC5848224 DOI: 10.1093/cid/cix559] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [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: 02/10/2017] [Accepted: 06/16/2017] [Indexed: 12/23/2022] Open
Abstract
Background Burkholderia cepacia complex (Bcc) are a group of multidrug-resistant gram-negative bacteria rarely reported in patients without cystic fibrosis (CF) or immunocompromising conditions. We investigated Bcc bloodstream infections (BSIs) in a cohort of non-CF patients from the US Veterans Health Administration (VHA). Methods Using VHA databases, we identified patients with Bcc BSI at facilities nationwide from 1999 through 2015. We ascertained clinical characteristics, treatments, and outcomes and identified factors associated with 30-day mortality in logistic regression analysis. Results We identified 248 patients with Bcc BSI, who were of advanced age (mean, 68 years), chronically ill, and had severe disease. The most common sources were central venous catheters (41%) and pneumonia (20%). Most cases were hospital-acquired (155 [62%]) or healthcare-associated (70 [28%]). Mortality at 14, 30, and 90 days was 16%, 25%, and 36%, respectively. Trimethoprim-sulfamethoxazole (TMP-SMX) and fluoroquinolones were active against 94% and 88% of isolates, respectively. Susceptibility to ceftazidime and meropenem occurred in approximately 70% of the isolates. The most prescribed antibiotics were fluoroquinolones (35%), followed by carbapenems (20%), TMP-SMX (18.5%), and ceftazidime (11%). In regression analysis, age (OR, 1.06 [95% confidence interval {CI}, 1.02-1.10], per added year) and the Pitt bacteremia score (OR, 1.65 [95% CI, 1.44-1.94], per unit increase) were associated with higher 30-day mortality. Conclusions In this large cohort of BSIs caused by Bcc, cases were mostly hospital-acquired and we observed high mortality, significant resistance to ceftazidime, and limited use of TMP-SMX. These observations add to our understanding of Bcc infection in non-CF patients and highlight the need for interventions to improve their outcome.
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Affiliation(s)
- Nadim G El Chakhtoura
- Department of Medicine, University Hospitals Cleveland Medical Center
- Medicine and
- Research Services and
- Geriatrics Research, Education and Clinical Center, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, and
| | - Elie Saade
- Department of Medicine, University Hospitals Cleveland Medical Center
- Medicine and
- Research Services and
| | | | - Federico Perez
- Department of Medicine, University Hospitals Cleveland Medical Center
- Medicine and
- Research Services and
| | - Krisztina M Papp-Wallace
- Department of Medicine, University Hospitals Cleveland Medical Center
- Research Services and
- Departments of Pharmacology and
| | - Robert A Bonomo
- Department of Medicine, University Hospitals Cleveland Medical Center
- Medicine and
- Research Services and
- Geriatrics Research, Education and Clinical Center, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, and
- Departments of Pharmacology and
- Biochemistry and
- Molecular Biology and Microbiology, Case Western Reserve University School of Medicine, Cleveland, Ohio
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