Implementation of a Prevention Bundle to Decrease Rates of Staphylococcus aureus Surgical Site Infection at 11 Veterans Affairs Hospitals

Importance

While current evidence has demonstrated a surgical site infection (SSI) prevention bundle consisting of preoperative Staphylococcus aureus screening, nasal and skin decolonization, and use of appropriate perioperative antibiotic based on screening results can decrease rates of SSI caused by S aureus, it is well known that interventions may need to be modified to address facility-level factors.

Objective

To assess the association between implementation of an SSI prevention bundle allowing for facility discretion regarding specific component interventions and S aureus deep incisional or organ space SSI rates.

Design, Setting, and Participants

This quality improvement study was conducted among all patients who underwent coronary artery bypass grafting, cardiac valve replacement, or total joint arthroplasty (TJA) at 11 Veterans Administration hospitals. Implementation of the bundle was on a rolling basis with the earliest implementation occurring in April 2012 and the latest implementation occurring in July 2017. Data were collected from January 2007 to March 2018 and analyzed from October 2020 to June 2023.

Interventions

Nasal screening for S aureus; nasal decolonization of S aureus carriers; chlorhexidine bathing; and appropriate perioperative antibiotic prophylaxis according to S aureus carrier status. Facility discretion regarding how to implement the bundle components was allowed.

Main Outcomes and Measures

The primary outcome was deep incisional or organ space SSI caused by S aureus. Multivariable logistic regression with generalized estimating equation (GEE) and interrupted time-series (ITS) models were used to compare SSI rates between preintervention and postintervention periods.

Results

Among 6696 cardiac surgical procedures and 16 309 TJAs, 95 S aureus deep incisional or organ space SSIs were detected (25 after cardiac operations and 70 after TJAs). While the GEE model suggested a significant association between the intervention and decreased SSI rates after TJAs (adjusted odds ratio, 0.55; 95% CI, 0.31-0.98), there was not a significant association when an ITS model was used (adjusted incidence rate ratio, 0.88; 95% CI, 0.32-2.39). No significant associations after cardiac operations were found.

Conclusions and Relevance

Although this quality improvement study suggests an association between implementation of an SSI prevention bundle and decreased S aureus deep incisional or organ space SSI rates after TJAs, it was underpowered to see a significant difference when accounting for changes over time.

Clinician Attitudes and Beliefs Associated with More Aggressive Diagnostic Testing

BACKGROUND

Variation in clinicians' diagnostic test utilization is incompletely explained by demographics and likely relates to cognitive characteristics. We explored clinician factors associated with diagnostic test utilization.

METHODS

We used a self-administered survey of attitudes, cognitive characteristics, and reported likelihood of test ordering in common scenarios; frequency of lipid and liver testing in patients on statin therapy. Participants were 552 primary care physicians, nurse practitioners, and physician assistants from practices in 8 US states across 3 regions, from June 1, 2018 to November 26, 2019. We measured Testing Likelihood Score: the mean of 4 responses to testing frequency and self-reported testing frequency in patients on statins.

RESULTS

Respondents were 52.4% residents, 36.6% attendings, and 11.0% nurse practitioners/physician assistants; most were white (53.6%) or Asian (25.5%). Median age was 32 years; 53.1% were female. Participants reported ordering tests for a median of 20% (stress tests) to 90% (mammograms) of patients; Testing Likelihood Scores varied widely (median 54%, interquartile range 43%-69%). Higher scores were associated with geography, training type, low numeracy, high malpractice fear, high medical maximizer score, high stress from uncertainty, high concern about bad outcomes, and low acknowledgment of medical uncertainty. More frequent testing of lipids and liver tests was associated with low numeracy, high medical maximizer score, high malpractice fear, and low acknowledgment of uncertainty.

CONCLUSIONS

Clinician variation in testing was common, with more aggressive testing consistently associated with low numeracy, being a medical maximizer, and low acknowledgment of uncertainty. Efforts to reduce undue variations in testing should consider clinician cognitive drivers.

Increased carbapenemase testing following implementation of national VA guidelines for carbapenem-resistant Enterobacterales (CRE)

OBJECTIVE

To describe national trends in testing and detection of carbapenemases produced by carbapenem-resistant Enterobacterales (CRE) and associate testing with culture and facility characteristics.

DESIGN

Retrospective cohort study.

SETTING

Department of Veterans' Affairs medical centers (VAMCs).

PARTICIPANTS

Patients seen at VAMCs between 2013 and 2018 with cultures positive for CRE, defined by national VA guidelines.

INTERVENTIONS

Microbiology and clinical data were extracted from national VA data sets. Carbapenemase testing was summarized using descriptive statistics. Characteristics associated with carbapenemase testing were assessed with bivariate analyses.

RESULTS

Of 5,778 standard cultures that grew CRE, 1,905 (33.0%) had evidence of molecular or phenotypic carbapenemase testing and 1,603 (84.1%) of these had carbapenemases detected. Among these cultures confirmed as carbapenemase-producing CRE, 1,053 (65.7%) had molecular testing for ≥1 gene. Almost all testing included KPC (n = 1,047, 99.4%), with KPC detected in 914 of 1,047 (87.3%) cultures. Testing and detection of other enzymes was less frequent. Carbapenemase testing increased over the study period from 23.5% of CRE cultures in 2013 to 58.9% in 2018. The South US Census region (38.6%) and the Northeast (37.2%) region had the highest proportion of CRE cultures with carbapenemase testing. High complexity (vs low) and urban (vs rural) facilities were significantly associated with carbapenemase testing (P < .0001).

CONCLUSIONS

Between 2013 and 2018, carbapenemase testing and detection increased in the VA, largely reflecting increased testing and detection of KPC. Surveillance of other carbapenemases is important due to global spread and increasing antibiotic resistance. Efforts supporting the expansion of carbapenemase testing to low-complexity, rural healthcare facilities and standardization of reporting of carbapenemase testing are needed.

Coronavirus disease 2019 (COVID-19) research agenda for healthcare epidemiology

This SHEA white paper identifies knowledge gaps and challenges in healthcare epidemiology research related to coronavirus disease 2019 (COVID-19) with a focus on core principles of healthcare epidemiology. These gaps, revealed during the worst phases of the COVID-19 pandemic, are described in 10 sections: epidemiology, outbreak investigation, surveillance, isolation precaution practices, personal protective equipment (PPE), environmental contamination and disinfection, drug and supply shortages, antimicrobial stewardship, healthcare personnel (HCP) occupational safety, and return to work policies. Each section highlights three critical healthcare epidemiology research questions with detailed description provided in supplementary materials. This research agenda calls for translational studies from laboratory-based basic science research to well-designed, large-scale studies and health outcomes research. Research gaps and challenges related to nursing homes and social disparities are included. Collaborations across various disciplines, expertise and across diverse geographic locations will be critical.

Strategies for the implementation of a nasal decolonization intervention to prevent surgical site infections within the Veterans Health Administration

As part of a multicenter evidence-based intervention for surgical site infection prevention, a qualitative study was conducted with infection control teams and surgical staff members at three Department of Veterans Affairs Healthcare Systems in the USA. This study aimed to identify strategies used by nurses and other facility champions for the implementation of a nasal decolonization intervention. Site visit observations and field notes provided contextual information. Interview data were analyzed with inductive and deductive content analysis. Interview data was mapped to the Expert Recommendations for Implementing Change (ERIC) compilation of implementation strategies. These strategies were then considered in the context of power and relationships as factors that influence implementation. We found that implementation of this evidence-based surgical site infection prevention intervention was successful when nurse champions drove the day-to-day implementation. Nurse champions sustained implementation strategies through all phases of implementation. Findings also suggest that nurse champions leveraged the influence of their role as champion along with their understanding of social networks and relationships to help achieve implementation success. Nurse champions consciously used multiple overlapping and iterative implementation strategies, adapting and tailoring strategies to stakeholders and settings. Commonly used implementation categories included: "train and educate stakeholders," "use evaluative and iterative strategies," "adapt and tailor to context," and "develop stakeholder interrelationships." Future research should examine the social networks for evidence-based interventions by asking specifically about relationships and power dynamics within healthcare organizations. Implementation of evidence-based interventions should consider if the tasks expected of a nurse champion fit the level of influence or power held by the champion.

Trial registration

ClinicalTrials.gov, identifier: NCT02216227.

1351. Use of Mail-Out Sexually Transmitted Infection Test Kits in a Telehealth Pre-exposure Prophylaxis Clinic

Background

Standard of care for patients receiving pre-exposure prophylaxis (PrEP) for human immunodeficiency virus (HIV) includes HIV screening and testing for sexually transmitted infections (STIs) at all sites of potential exposure every three months. We implemented a provider and pharmacist telehealth based PrEP program as part of the HIV, Hepatitis Specialty Telehealth Access Resource (H-START) Collaborative. Due to the COVID-19 pandemic and care via telehealth, we had limited ability to collect pharyngeal or rectal swabs in clinic. We created mail-out kits including swabs and instructions for self-collection to test for rectal and pharyngeal Neisseria gonorrhea and Chlamydia trachomatis.

Methods

Kits were mailed out to patients between June 2020 and May 2021. Providers first confirmed patient comfort with self-swab collection during telehealth appointments. Kits included: an instruction sheet with visual diagrams for collection, swabs with appropriate labels; and a pre-paid envelope for patients to mail swabs back to our facility for laboratory testing. Prospective data collection included the date kits were mailed out to patients, the date of kit receipt at our facility and the test result. Charts were retrospectively reviewed to determine treatment completion.

Results

54 self-swab kits were mailed to patients. 53 of the patients were male and the average age was 41.3 years old. 38 (70.3%) swabs were returned. The median time for return of swabs was 21 days (Range 2-289). Of those returned, 5 (13.1%) were positive and all 5 patients were treated for their infection.

Conclusion

Mail-out STI testing was effective in identifying STIs for a telehealth PrEP program and for maintaining standard of care practice during the COVID-19 pandemic. This model may increase rates of testing compliance for care provided via telehealth and decrease rates of STI transmission and complications. Better communication around returning kits in a timely-manner and understanding reasons for non-return warrant further investigation.

Disclosures

Monica K. Sikka, MD, FG2 (Scientific Research Study Investigator) Christopher D. Pfeiffer, MD, MHS, C. difficile Vaccine Trial (Scientific Research Study Investigator)

Construction and validation of an ultraviolet germicidal irradiation system using locally available components

Coronavirus disease (COVID-19), the disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus, is responsible for a global pandemic characterized by high transmissibility and morbidity. Healthcare workers (HCWs) are at risk of contracting COVID-19, but this risk has been mitigated through the use of personal protective equipment such as N95 Filtering Facepiece Respirators (FFRs). At times the high demand for FFRs has exceeded supply, placing HCWs at increased exposure risk. Effective FFR decontamination of many FFR models using ultraviolet-C germicidal irradiation (UVGI) has been well-described, and could maintain respiratory protection for HCWs in the face of supply line shortages. Here, we detail the construction of an ultraviolet-C germicidal irradiation (UVGI) device using previously existing components available at our institution. We provide data on UV-C dosage delivered with our version of this device, provide information on how users can validate the UV-C dose delivered in similarly constructed systems, and describe a simple, novel methodology to test its germicidal effectiveness using in-house reagents and equipment. As similar components are readily available in many hospitals and industrial facilities, we provide recommendations on the local construction of these systems, as well as guidance and strategies towards successful institutional implementation of FFR decontamination.

Implementing daily chlorhexidine gluconate (CHG) bathing in VA settings: The human factors engineering to prevent resistant organisms (HERO) project

BACKGROUND

Daily use of chlorhexidine gluconate (CHG) has been shown to reduce risk of healthcare-associated infections. We aimed to assess moving CHG bathing into routine practice using a human factors approach. We evaluated implementation in non-intensive care unit (ICU) settings in the Veterans Health Administration.

METHODS

Our multiple case study approach included non-ICU units from 4 Veterans Health Administration settings. Guided by the Systems Engineering Initiative for Patient Safety, we conducted focus groups and interviews to capture barriers and facilitators to daily CHG bathing. We measured compliance using observations and skin CHG concentrations.

RESULTS

Barriers to daily CHG include time, concern of increasing antibiotic resistance, workflow and product concerns. Facilitators include engagement of champions and unit shared responsibility. We found shortfalls in patient education, hand hygiene and CHG use on tubes and drains. CHG skin concentration levels were highest among patients from spinal cord injury units. These units applied antiseptic using 2% CHG impregnated wipes vs 4% CHG solution/soap.

DISCUSSION

Non-ICUs implementing CHG bathing must consider human factors and work system barriers to ensure uptake and sustained practice change.

CONCLUSIONS

Well-planned rollouts and a unit culture promoting shared responsibility are key to compliance with daily CHG bathing. Successful implementation requires attention to staff education and measurement of compliance.

Risk Factors Associated with Carbapenemase Producing Carbapenem-Resistant Enterobacteriaceae (CP-CRE) Positive Cultures in a Cohort of U.S. Veterans

INTRODUCTION

Carbapenem-resistant Enterobacterales (CRE) cause approximately 13,100 infections with 8% mortality in the United States annually. The subset of carbapenemase-producing CRE (CP-CRE) infections have much higher mortality rates (40% -50%). There has been little research on characteristics unique to CP-CRE. The goal of this study was to assess differences between those with nonCP-CRE and CP-CRE cultures in U.S. Veterans.

METHODS

A retrospective cohort of Veterans with CRE cultures from 2013-2018 and their demographic, medical, and facility level covariates were collected. Clustered multiple logistic regression models were used to assess independent factors associated with CP-CRE.

RESULTS

3,096 unique patients with cultures positive for either nonCP-CRE or CP-CRE were included. Being African American (Odds Ratio (OR)=1.44 (95% Confidence Interval (CI) 1.15,1.80), diagnosis in 2017 (OR=3.11 (95% CI 2.13,4.54)) or 2018 (OR=3.93 (95%CI 2.64,5.84)), congestive heart failure (OR=1.35 (95%CI 1.11,1.64)), and gastroesophageal reflux disease (OR=1.39 (95%CI 1.03,1.87)) were associated with CP-CRE cultures. 752 (24.3%) patients had no known antibiotic exposure in the year before culture; these individuals had a comparatively increased frequency of prolonged PPI use (17.3% vs 5.6%).

DISCUSSION

Among a cohort of patients with CRE, African Americans, individuals with congestive heart failure, and patients with gastroesophageal reflux disease had greater odds of having a CP-CRE culture. Roughly one in four patients with CP-CRE had no known antibiotic exposure in the year before their positive culture.

843. Increased Carbapenemase Testing Following Implementation of VA Guidelines for Carbapenem-Resistant Enterobacteriaceae (CRE)

Background

Carbapenem-resistant Enterobacteriaceae (CRE) are a substantial burden, with recent data showing no change in hospital CRE between 2012-2017. All carbapenemases produced by CRE have been identified in the U.S., however trends in testing and detection over time have not been well described.

Trends in carbapenemase testing in the VA, 2013-2018

Methods

A retrospective cohort study of Veterans hospitalized between 2013-2018 with CRE cultures defined by either 2015 or 2017 VA guidelines. In general, this was Escherichia coli, Klebsiella pneumoniae/oxytoca, or Enterobacter spp. non-susceptible to imipenem, meropenem, and/or doripenem, and to 3^rd generation cephalosporins for 2015 definition. Testing for Klebsiella pneumoniae carbapenemase (KPC), New Dehli metallo-β-lactamase (NDM), Verona integron-encoded metallo-β-lactamase (VIM), Imipenemase (IMP), and Oxacillinase-48-like (OXA-48) was summarized with descriptive statistics. Facility characteristics assessed included region, complexity, and rurality.

Results

Out of 5,778 CRE cultures, 1,900 (32.9%) were tested for carbapenemases and 1,612 (84.8%) of these had carbapenemases detected. Among CP-CRE cultures, 1,042 (64.6%) had testing for ≥1 genetic mechanism; all tests included KPC. Testing for NDM (n=585, 56.1%), VIM (n=102, 9.8%), IMP (n=102, 9.8%), and OXA-48 (n=507, 48.7%) was less frequent. KPC was detected in 915/1,042 cultures (87.8%), while NDM (n=7/585, 1.2%) was rarely detected. There were no cases of VIM, IMP, or OXA-48. Carbapenemase testing increased significantly over the study period; KPC, NDM, and OXA-48 were the predominant mechanisms tested (Figure 1). The South (38.6%) and Northeast (37.2%) had the highest proportion of CRE with carbapenemase testing. High complexity (vs low) and urban (vs rural) facilities were significantly associated with carbapenemase testing (p< 0.001).

Conclusion

Following publication of initial CRE guidelines in 2015, carbapenemase testing and detection increased in the VA, although tests for non-KPC carbapenemases were less frequent. Surveillance of non-KPC carbapenemases is important due to global dissemination and enhanced antibiotic resistance. Efforts should support carbapenemase testing in low complexity, rural facilities in the Midwest and West.

Disclosures

All Authors: No reported disclosures

Homegrown Ultraviolet Germicidal Irradiation for Hospital-Based N95 Decontamination during the COVID-19 Pandemic

Coronavirus disease (COVID-19), the disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus, is responsible for the 2020 global pandemic and characterized by high transmissibility and morbidity. Healthcare workers (HCWs) are at risk of contracting COVID-19, and this risk is mitigated through the use of personal protective equipment such as N95 Filtering Facepiece Respirators (FFRs). The high demand for FFRs is not currently met by global supply chains, potentially placing HCWs at increased exposure risk. Effective FFR decontamination modalities exist, which could maintain respiratory protection for HCWs in the midst of the current pandemic, through the decontamination and re-use of FFRs. Here, we present a locally-implemented ultraviolet-C germicidal irradiation (UVGI)-based FFR decontamination pathway, utilizing a home-built UVGI array assembled entirely with previously existing components available at our institution. We provide recommendations on the construction of similar systems, as well as guidance and strategies towards successful institutional implementation of FFR decontamination.

Compliance with statewide regulations for communication of patients' multidrug-resistant organism and Clostridium difficile status during transitions of care

In 2014, Oregon implemented an interfacility transfer communication law requiring notification of multidrug-resistant organism status on patient transfer. Based on 2015 and 2016 statewide facility surveys, compliance was 77% and 87% for hospitals, and 67% and 68% for skilled nursing facilities. Methods for complying with the rule were heterogeneous, and fewer than half of all facilities surveyed reported use of a standardized interfacility transfer communication form to assess a patient's multidrug-resistant organism status on transfer.

Laboratory practices for identification and reporting of carbapenem-resistant Enterobacteriaceae in Department of Veterans Affairs facilities

Laboratory identification of carbapenem-resistant Enterobacteriaceae (CRE) is a key step in controlling its spread. Our survey showed that most Veterans Affairs laboratories follow VA guidelines for initial CRE identification, whereas 55.0% use PCR to confirm carbapenemase production. Most respondents were knowledgeable about CRE guidelines. Barriers included staffing, training, and financial resources.

Rapid detection of blaOXA in carbapenem-susceptible Acinetobacter radioresistens bacteremia leading to unnecessary antimicrobial administration

Rapid molecular techniques to identify resistant pathogens are revolutionizing antibiotic stewardship; however, it is important to recognize the limitations of these techniques. Herein we describe two cases of bacteremia that were both initially identified by genotypic testing as carbapenem-resistant Acinetobacter spp. and subsequently identified phenotypically as carbapenem-susceptible A. radioresistens. The genotypic results prompted unnecessary broad-spectrum antibiotic use and infection control concerns.

Skin infections in returned travelers: an update

Dermatologic manifestations of travel-related illness are particularly vexing due to the broad differential diagnosis and clinicians' unfamiliarity with uncommonly seen diseases. This paper aims to educate and update the reader on selected infectious diseases in the returned traveler whose disease manifestations are primarily dermatologic. First, the evolving epidemiology of these infections is examined; understanding the geographic distribution of infectious etiologies helps refine and narrow the differential diagnosis. This is followed by a discussion of six important clinical syndromes including cutaneous larva migrans (CLM), cutaneous leishmaniasis, tungiasis, myiasis, antibiotic-resistant skin and soft tissue infection, and selected infections associated with fever and rash (e.g., measles, chikungunya virus infection, dengue fever, rickettsial spotted fevers). Familiarity with these syndromes and a situational awareness of their epidemiology will facilitate a prompt, accurate diagnosis and lead to appropriate treatment and prevention of further disease spread.

Establishment of a statewide network for carbapenem-resistant enterobacteriaceae prevention in a low-incidence region

OBJECTIVE

To establish a statewide network to detect, control, and prevent the spread of carbapenem-resistant Enterobacteriaceae (CRE) in a region with a low incidence of CRE infection.

DESIGN

Implementation of the Drug Resistant Organism Prevention and Coordinated Regional Epidemiology (DROP-CRE) Network.

SETTING AND PARTICIPANTS

Oregon infection prevention and microbiology laboratory personnel, including 48 microbiology laboratories, 62 acute care facilities, and 140 long-term care facilities.

METHODS

The DROP-CRE working group, comprising representatives from academic institutions and public health, convened an interdisciplinary advisory committee to assist with planning and implementation of CRE epidemiology and control efforts. The working group established a statewide CRE definition and surveillance plan; increased the state laboratory capacity to perform the modified Hodge test and polymerase chain reaction for carbapenemases in real time; and administered surveys that assessed the needs and capabilities of Oregon infection prevention and laboratory personnel. Results of these inquiries informed CRE education and the response plan.

RESULTS

Of 60 CRE reported from November 2010 through April 2013, only 3 were identified as carbapenemase producers; the cases were not linked, and no secondary transmission was found. Microbiology laboratories, acute care facilities, and long-term care facilities reported lacking carbapenemase testing capability, reliable interfacility communication, and CRE awareness, respectively. Survey findings informed the creation of the Oregon CRE Toolkit, a state-specific CRE guide booklet.

CONCLUSIONS

A regional epidemiology surveillance and response network has been implemented in Oregon in advance of widespread CRE transmission. Prospective surveillance will determine whether this collaborative approach will be successful at forestalling the emergence of this important healthcare-associated pathogen.

Much to do about carbapenem-resistant Enterobacteriaceae: why supplementing surveillance may be the key to stopping spread

(See the article by Thaden et al, on pages 978–983.)

It is critical to the future of public health to understand the burden of carbapenem-resistant Enterobacteriaceae (CRE) so that we can effectively target efforts to limit potential spread. The Centers for Disease Control and Prevention (CDC) classifies CRE as 1 of 3 “urgent” antibiotic resistance threats to public health because of the high mortality associated with CRE infection and its rapid dissemination in the United States.

What is the current burden of CRE disease? We can glean a snapshot of the national epidemiology of CRE from the CDC’s national surveillance. Rapid geographic spread is evident in the CDC’s national map of CRE, which indicates that all but 3 states now have identified CRE. Incidence by facility type, procedure, device, and organism all have considerable variation, providing preliminary indications where future prevention efforts might best be focused. The 2013 CRE Vital Signs states that 3.9% of short-stay acute care hospitals and 17.8% of long-term acute care hospitals have identified cases of CRE infection among those with catheter-associated urinary tract infection (CAUTI) or central line–associated bloodstream infection (CLABSI). The CDC also reported that 10% of Klebsiella species in intensive care unit (ICU) CLABSIs, ICU CAUTIs, and surgical site infections after colon surgery or coronary artery bypass grafting in 2011 were carbapenem resistant. Although CRE have been reported in most states, it is increasingly clear that wide regional variation exists, from regions of hyperendemicity, such as parts of New York City, to regions apparently free of CRE, such as Maine.

A cross-sectional analysis of HIV and hepatitis C clinical trials 2007 to 2010: the relationship between industry sponsorship and randomized study design

BACKGROUND

The proportion of clinical research sponsored by industry will likely continue to expand as federal funds for academic research decreases, particularly in the fields of HIV/AIDS and hepatitis C (HCV). While HIV and HCV continue to burden the US population, insufficient data exists as to how industry sponsorship affects clinical trials involving these infectious diseases. Debate exists about whether pharmaceutical companies undertake more market-driven research practices to promote therapeutics, or instead conduct more rigorous trials than their non-industry counterparts because of increased resources and scrutiny. The ClinicalTrials.gov registry, which allows investigators to fulfill a federal mandate for public trial registration, provides an opportunity for critical evaluation of study designs for industry-sponsored trials, independent of publication status. As part of a large public policy effort, the Clinical Trials Transformation Initiative (CTTI) recently transformed the ClinicalTrials.gov registry into a searchable dataset to facilitate research on clinical trials themselves.

METHODS

We conducted a cross-sectional analysis of 477 HIV and HCV drug treatment trials, registered with ClinicalTrials.gov from 1 October 2007 to 27 September 2010, to study the relationship of study sponsorship with randomized study design. The likelihood of using randomization given industry (versus non-industry) sponsorship was reported with prevalence ratios (PR). PRs were estimated using crude and stratified tabular analysis and Poisson regression adjusting for presence of a data monitoring committee, enrollment size, study phase, number of study sites, inclusion of foreign study sites, exclusion of persons older than age 65, and disease condition.

RESULTS

The crude PR was 1.17 (95% CI 0.94, 1.45). Adjusted Poisson models produced a PR of 1.13 (95% CI 0.82, 1.56). There was a trend toward mild effect measure modification by study phase, but this was not statistically significant. In stratified tabular analysis the adjusted PR was 1.14 (95% CI 0.78, 1.68) among phase 2/3 trials and 1.06 (95% CI 0.50, 2.22) among phase 4 trials.

CONCLUSIONS

No significant relationship was found between industry sponsorship and use of randomization in trial design in this cross-sectional study. Prospective studies evaluating other aspects of trial design may shed further light on the relationship between industry sponsorship and appropriate trial methodology.

The state of infectious diseases clinical trials: a systematic review of ClinicalTrials.gov

Background

There is a paucity of clinical trials informing specific questions faced by infectious diseases (ID) specialists. The ClinicalTrials.gov registry offers an opportunity to evaluate the ID clinical trials portfolio.

Methods

We examined 40,970 interventional trials registered with ClinicalTrials.gov from 2007–2010, focusing on study conditions and interventions to identify ID-related trials. Relevance to ID was manually confirmed for each programmatically identified trial, yielding 3570 ID trials and 37,400 non-ID trials for analysis.

Results

The number of ID trials was similar to the number of trials identified as belonging to cardiovascular medicine (n = 3437) or mental health (n = 3695) specialties. Slightly over half of ID trials were treatment-oriented trials (53%, vs. 77% for non-ID trials) followed by prevention (38%, vs. 8% in non-ID trials). ID trials tended to be larger than those of other specialties, with a median enrollment of 125 subjects (interquartile range [IQR], 45–400) vs. 60 (IQR, 30–160) for non-ID trials. Most ID studies are randomized (73%) but nonblinded (56%). Industry was the funding source in 51% of ID trials vs. 10% that were primarily NIH-funded. HIV-AIDS trials constitute the largest subset of ID trials (n = 815 [23%]), followed by influenza vaccine (n = 375 [11%]), and hepatitis C (n = 339 [9%]) trials. Relative to U.S. and global mortality rates, HIV-AIDS and hepatitis C virus trials are over-represented, whereas lower respiratory tract infection trials are under-represented in this large sample of ID clinical trials.

Conclusions

This work is the first to characterize ID clinical trials registered in ClinicalTrials.gov, providing a framework to discuss prioritization, methodology, and policy.

Increasing echinocandin resistance in Candida glabrata: clinical failure correlates with presence of FKS mutations and elevated minimum inhibitory concentrations

BACKGROUND

Fluconazole (FLC) resistance is common in C. glabrata and echinocandins are often used as first-line therapy. Resistance to echinocandin therapy has been associated with FKS1 and FKS2 gene alterations.

METHODS

We reviewed records of all patients with C. glabrata bloodstream infection at Duke Hospital over the past decade (2001-2010) and correlated treatment outcome with minimum inhibitory concentration (MIC) results and the presence of FKS gene mutations. For each isolate, MICs to FLC and echinocandins (anidulafungin, caspofungin, and micafungin) and FKS1 and FKS2 gene sequences were determined.

RESULTS

Two hundred ninety-three episodes (313 isolates) of C. glabrata bloodstream infection were analyzed. Resistance to echinocandins increased from 4.9% to 12.3% and to FLC from 18% to 30% between 2001 and 2010, respectively. Among the 78 FLC resistant isolates, 14.1% were resistant to 1 or more echinocandin. Twenty-five (7.9%) isolates harbored a FKS mutation. The predictor of a FKS mutant strain was prior echinocandin therapy (stepwise multivariable analysis, odds ratio, 19.647 [95% confidence interval, 7.19-58.1]). Eighty percent (8/10) of patients infected with FKS mutants demonstrating intermediate or resistant MICs to an echinocandin and treated with an echinocandin failed to respond or responded initially but experienced a recurrence.

CONCLUSIONS

Echinocandin resistance is increasing, including among FLC-resistant isolates. The new Clinical and Laboratory Standards Institute clinical breakpoints differentiate wild-type from C. glabrata strains bearing clinically significant FKS1/FKS2 mutations. These observations underscore the importance of knowing the local epidemiology and resistance patterns for Candida within institutions and susceptibility testing of echinocandins for C. glabrata to guide therapeutic decision making.

β-D-glucan surveillance with preemptive anidulafungin for invasive candidiasis in intensive care unit patients: a randomized pilot study

BACKGROUND

Invasive candidiasis (IC) is a devastating disease. While prompt antifungal therapy improves outcomes, empiric treatment based on the presence of fever has little clinical impact. Β-D-Glucan (BDG) is a fungal cell wall component detectable in the serum of patients with early invasive fungal infection (IFI). We evaluated the utility of BDG surveillance as a guide for preemptive antifungal therapy in at-risk intensive care unit (ICU) patients.

METHODS

Patients admitted to the ICU for ≥ 3 days and expected to require at least 2 additional days of intensive care were enrolled. Subjects were randomized in 3:1 fashion to receive twice weekly BDG surveillance with preemptive anidulafungin in response to a positive test or empiric antifungal treatment based on physician preference.

RESULTS

Sixty-four subjects were enrolled, with 1 proven and 5 probable cases of IC identified over a 2.5 year period. BDG levels were higher in subjects with proven/probable IC as compared to those without an IFI (117 pg/ml vs. 28 pg/ml; p<0.001). Optimal assay performance required 2 sequential BDG determinations of ≥ 80 pg/ml to define a positive test (sensitivity 100%, specificity 75%, positive predictive value 30%, negative predictive value 100%). In all, 21 preemptive and 5 empiric subjects received systemic antifungal therapy. Receipt of preemptive antifungal treatment had a significant effect on BDG concentrations (p< 0.001). Preemptive anidulafungin was safe and generally well tolerated with excellent outcome.

CONCLUSIONS

BDG monitoring may be useful for identifying ICU patients at highest risk to develop an IFI as well as for monitoring treatment response. Preemptive strategies based on fungal biomarkers warrant further study.

TRIAL REGISTRATION

Clinical Trials.gov NCT00672841.

Epidemiologic features of human babesiosis in Wisconsin, 1996-2005

OBJECTIVE

To characterize epidemiologic, clinical, and laboratory features of babesiosis occurring in Wisconsin residents.

DESIGN

Conduct a review of all cases of babesiosis reported to the Wisconsin Division of Public Health with onsets during 1996-2005. For case patients with onsets during 2004, pertinent medical records were reviewed and patient interviews were performed.

INTERVENTIONS

Increase awareness of the occurrence and recent trends and facilitate prompt, appropriate diagnosis and treatment of babesiosis. Increase awareness among clinicians of the Infectious Diseases Society of America guidelines for the management of babesiosis, Lyme disease, and human granulocytic anaplasmosis.

MAIN OUTCOME MEASURES

The study represents an analysis of data received through passive surveillance of a disease that is officially reportable to the Wisconsin Division of Public Health. Other than the description of the occurrence of babesiosis among Wisconsin residents, there were no planned outcome measures.

RESULTS

Of the 32 cases of babesiosis reported to the DPH during the study interval, 23 (72%) occurred during 2004 and 2005. The majority of cases occurred in northwestern and west-central Wisconsin. At least 6 patients were co-infected with other tick-borne pathogens. Anemia, thrombocytopenia, and elevation of liver transaminase levels were the most notable laboratory abnormalities among case patients.

CONCLUSIONS

The apparent increased incidence in babesiosis among Wisconsin residents should impact clinicians' workups for acute febrile illness with known tick exposure, especially in northwest and west central Wisconsin. Babesiosis should now also be considered in patients diagnosed with Lyme disease who have marked constitutional symptoms, especially those with anemia or thrombocytopenia.

Diagnosis of Invasive Aspergillosis Using a Galactomannan Assay: A Meta-Analysis

BACKGROUND

A double-sandwich enzyme-linked immunosorbent galactomannan assay has been approved for surveillance for invasive aspergillosis in immunocompromised patients. We undertook a meta-analysis to assess the accuracy of a galactomannan assay for diagnosing invasive aspergillosis.

METHODS

Studies of the galactomannan assay that used the European Organization for Research and Treatment of Cancer or similar criteria as a reference standard and provided data to calculate sensitivity and specificity were included. Pooled sensitivity and specificity and summary measures of accuracy, Q* (the upper left-most point on the summary receiver-operating characteristic curve), mean D (a log odds ratio), and Youden index were calculated. Subgroup analyses were performed to explore heterogeneity.

RESULTS

Twenty-seven studies from 1966 to 28 February 2005 were included. Overall, the galactomannan assay had a sensitivity of 0.71 (95% confidence interval [CI], 0.68-0.74) and specificity of 0.89 (95% CI, 0.88-0.90) for proven cases of invasive aspergillosis. The Youden index, mean D, and Q* were 0.54 (95% CI, 0.41-0.65), 2.74 (95% CI, 21.12-3.36), and 0.80 (95% CI, 0.74-0.86), respectively, indicating moderate accuracy. Subgroup analyses showed that the performance of the test differed by patient population and type of reference standard used. Significant heterogeneity was present.

CONCLUSIONS

The galactomannan assay has moderate accuracy for diagnosis of invasive aspergillosis in immunocompromised patients. The test is more useful in patients who have hematological malignancy or who have undergone hematopoietic cell transplantation than in solid-organ transplant recipients. Further studies with attention to the impact of antifungal therapy, rigorous assessment of false-positive test results, and assessment of the utility of the test under nonsurveillance conditions are needed.

Determination of related compounds in aspirin by liquid chromatography

A rapid liquid chromatographic procedure has been validated for the determination of salicylic acid, salsalate, acetylsalicylsalicylic acid, and acetylsalicylic anhydride in aspirin. Samples are dissolved in methylene chloride and analyzed directly by adsorption chromatography in a 7-min separation using an isocratic mobile phase. Recoveries averaged 99% over a 200-10,000 ppm concentration range with standard deviations of less than 4% for the four compounds of interest. Detection limits ranged from 5 to 36 ppm. Compared to a recently published reversed-phase liquid chromatographic procedure for analyzing aspirin, this method is twice as fast, more sensitive, and avoids the use of hydroxylic solvents which lead to degradation of aspirin and acetylsalicylic anhydride.