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Murphy ZR, Muzaffar AF, Massih SA, Klein EY, Dispenza MC, Fabre V, Hensley NB, Blumenthal KG, Alvarez-Arango S. Examining cefazolin utilization and perioperative anaphylaxis in patients with and without a penicillin allergy label: A cross-sectional study. J Clin Anesth 2024; 94:111377. [PMID: 38241788 PMCID: PMC10939842 DOI: 10.1016/j.jclinane.2024.111377] [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: 09/12/2023] [Revised: 01/03/2024] [Accepted: 01/04/2024] [Indexed: 01/21/2024]
Abstract
STUDY OBJECTIVE To compare the occurrence of cefazolin perioperative anaphylaxis (POA) in patients with and without a penicillin allergy label (PAL) to determine whether the prevalence of cefazolin POA differs based on the presence of a PAL. DESIGN Cross-sectional study. SETTING A large U.S. healthcare system in the Baltimore-D.C. region, July 2017 to July 2020. PATIENTS 112,817 surgical encounters across inpatient and outpatient settings in various specialties, involving 90,089 patients. Of these, 4876 (4.3%) encounters had a PAL. INTERVENTIONS Perioperative cefazolin administration within 4 h before surgery to 4 h after the procedure began. MEASUREMENTS The primary outcome was cefazolin POA in patients with and without PALs. Potential POA cases were identified based on tryptase orders or diphenhydramine administrations within the initial cefazolin administration to 6 h postoperatively. Verification included two validation steps. The first checked for hypersensitivity reaction (HSR) documentation, and the second, led by Allergy specialists, identified POA and the probable culprit. The secondary outcome looked at cefazolin use trends in patients with a PAL, stratified by setting and specialty. MAIN RESULTS Of 112,817 encounters, 1421 (1.3%) had possible cefazolin HSRs. Of these, 22 (1.5%) had POA, resulting in a 0.02% prevalence. Of these, 13 (59.1%) were linked to cefazolin and 9 (40.9%) attributed to other drugs. Only one cefazolin POA case had a PAL, indicating no significant difference in cefazolin POA prevalence between patients with and without PALs (p = 0.437). Perioperative cefazolin use in patients with PALs steadily increased from 2.6% to 6.0% between 2017 and 2020, specifically in academic settings. CONCLUSIONS The prevalence of cefazolin POA does not exhibit significant differences between patients with and without PALs, and notably, the incidence remains remarkably low. Based on these findings, it is advisable to view cefazolin as an acceptable choice for prophylaxis in patients carrying a PAL.
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Affiliation(s)
- Zachary R Murphy
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, United States of America
| | - Anum F Muzaffar
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, United States of America
| | - Sandra A Massih
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States of America
| | - Eili Y Klein
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States of America; Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, United States of America
| | - Melanie C Dispenza
- Division of Allergy and Clinical Immunology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States of America
| | - Valeria Fabre
- Division of Infectious Disease, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States of America
| | - Nadia B Hensley
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States of America
| | - Kimberly G Blumenthal
- Harvard Medical School, Boston, MA, United States of America; Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America; The Mongan Institute, Massachusetts General Hospital, Boston, MA, USA
| | - Santiago Alvarez-Arango
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States of America; Division of Allergy and Clinical Immunology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States of America; Department of Pharmacology and Molecular Science, Johns Hopkins School of Medicine, Baltimore, MD, United States of America.
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Goodman KE, Taneja M, Magder LS, Klein EY, Sutherland M, Sorongon S, Tamma PD, Resnik P, Harris AD. A multi-center validation of the electronic health record admission source and discharge location fields against the clinical notes for identifying inpatients with long-term care facility exposure. Infect Control Hosp Epidemiol 2024:1-6. [PMID: 38634555 DOI: 10.1017/ice.2024.37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Identifying long-term care facility (LTCF)-exposed inpatients is important for infection control research and practice, but ascertaining LTCF exposure is challenging. Across a large validation study, electronic health record data fields identified 76% of LTCF-exposed patients compared to manual chart review. OBJECTIVE Residence or recent stay in a long-term care facility (LTCF) is an important risk factor for antibiotic-resistant bacterial colonization. However, absent dedicated intake questionnaires or resource-intensive chart review, ascertaining LTCF exposure in inpatients is challenging. We aimed to validate the electronic health record (EHR) admission and discharge location fields against the clinical notes for identifying LTCF-exposed inpatients. METHODS We conducted a retrospective study of 1020 randomly sampled adult admissions between 2016 and 2021 across 12 University of Maryland Medical System hospitals. Using study-developed guidelines, we categorized the following data for LTCF exposure: each admission’s history & physical (H&P) note, each admission’s EHR-extracted “Admission Source,” and (3) the EHR-extracted admission and discharge locations for previous admissions (≤90 days). We estimated sensitivities, with 95% CIs, of H&P notes and of EHR admission/discharge location fields for detecting “current” and “any recent” (≤90 days, including current) LTCF exposure. RESULTS For detecting current LTCF exposure, the sensitivity of the index admission’s EHR-extracted “Admission Source” was 46% (95% CI: 35%–58%) and of the H&P note was 92% (83%–97%). For detecting any recent LTCF exposure, the sensitivity of “Admission Source” across the index and previous admissions was 32% (24%–41%), “Discharge Location” across previous admission(s) was 57% (47%–66%), and of the H&P note was 68% (59%–76%). The combined sensitivity of admission source and discharge location for detecting any recent LTCF exposure was 76% (67%–83%). CONCLUSIONS The EHR-obtained admission source and discharge location fields identified 76% of LTCF-exposed patients compared to chart review but disproportionately missed currently exposed patients.
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Affiliation(s)
- Katherine E Goodman
- Department of Epidemiology and Public Health, The University of Maryland School of Medicine, Baltimore, MD, USA
- The University of Maryland Institute for Health Computing, Bethesda, MD, USA
| | - Monica Taneja
- The University of Maryland School of Medicine, Baltimore, MD, USA
| | - Laurence S Magder
- Department of Epidemiology and Public Health, The University of Maryland School of Medicine, Baltimore, MD, USA
| | - Eili Y Klein
- Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mark Sutherland
- Departments of Emergency Medicine and Internal Medicine, The University of Maryland School of Medicine, Baltimore, MD, USA
| | - Scott Sorongon
- Department of Epidemiology and Public Health, The University of Maryland School of Medicine, Baltimore, MD, USA
| | - Pranita D Tamma
- Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Philip Resnik
- Department of Linguistics and Institute for Advanced Computer Studies, The University of Maryland, College Park, College Park, MD, USA
| | - Anthony D Harris
- Department of Epidemiology and Public Health, The University of Maryland School of Medicine, Baltimore, MD, USA
- The University of Maryland Institute for Health Computing, Bethesda, MD, USA
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St Clair LA, Eldesouki RE, Sachithanandham J, Yin A, Fall A, Morris CP, Norton JM, Abdullah O, Dhakal S, Barranta C, Golding H, Bersoff-Matcha SJ, Pilgrim-Grayson C, Berhane L, Cox AL, Burd I, Pekosz A, Mostafa HH, Klein EY, Klein SL. Reduced control of SARS-CoV-2 infection associates with lower mucosal antibody responses in pregnancy. mSphere 2024; 9:e0081223. [PMID: 38426787 PMCID: PMC10964408 DOI: 10.1128/msphere.00812-23] [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: 01/08/2024] [Accepted: 01/10/2024] [Indexed: 03/02/2024] Open
Abstract
Pregnant patients are at greater risk of hospitalization with severe COVID-19 than non-pregnant people. This was a retrospective observational cohort study of remnant clinical specimens from patients who visited acute care hospitals within the Johns Hopkins Health System in the Baltimore, MD-Washington DC, area between October 2020 and May 2022. Participants included confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-infected pregnant people and matched non-pregnant people (the matching criteria included age, race/ethnicity, area deprivation index, insurance status, and vaccination status to ensure matched demographics). The primary dependent measures were clinical COVID-19 outcomes, infectious virus recovery, viral RNA levels, and mucosal anti-spike (S) IgG titers from upper respiratory tract samples. A total of 452 individuals (117 pregnant and 335 non-pregnant) were included in the study, with both vaccinated and unvaccinated individuals represented. Pregnant patients were at increased risk of hospitalization (odds ratio [OR] = 4.2; confidence interval [CI] = 2.0-8.6), intensive care unit admittance (OR = 4.5; CI = 1.2-14.2), and being placed on supplemental oxygen therapy (OR = 3.1; CI = 1.3-6.9). Individuals infected during their third trimester had higher mucosal anti-S IgG titers and lower viral RNA levels (P < 0.05) than those infected during their first or second trimesters. Pregnant individuals experiencing breakthrough infections due to the Omicron variant had reduced anti-S IgG compared to non-pregnant patients (P < 0.05). The observed increased severity of COVID-19 and reduced mucosal antibody responses particularly among pregnant participants infected with the Omicron variant suggest that maintaining high levels of SARS-CoV-2 immunity through booster vaccines may be important for the protection of this at-risk population.IMPORTANCEIn this retrospective observational cohort study, we analyzed remnant clinical samples from non-pregnant and pregnant individuals with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections who visited the Johns Hopkins Hospital System between October 2020 and May 2022. Disease severity, including intensive care unit admission, was greater among pregnant than non-pregnant patients. Vaccination reduced recovery of infectious virus and viral RNA levels in non-pregnant patients, but not in pregnant patients. In pregnant patients, increased nasopharyngeal viral RNA levels and recovery of infectious virus were associated with reduced mucosal IgG antibody responses, especially among women in their first trimester of pregnancy or experiencing breakthrough infections from Omicron variants. Taken together, this study provides insights into how pregnant patients are at greater risk of severe COVID-19. The novelty of this study is that it focuses on the relationship between the mucosal antibody response and its association with virus load and disease outcomes in pregnant people, whereas previous studies have focused on serological immunity. Vaccination status, gestational age, and SARS-CoV-2 omicron variant impact mucosal antibody responses and recovery of infectious virus from pregnant patients.
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Affiliation(s)
- Laura A. St Clair
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Raghda E. Eldesouki
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Medical Genetics Unit, School of Medicine, Suez Canal University, Ismailia, Egypt
| | - Jaiprasath Sachithanandham
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Anna Yin
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Amary Fall
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - C. Paul Morris
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, Maryland, USA
| | - Julie M. Norton
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Omar Abdullah
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Santosh Dhakal
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Caelan Barranta
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Hana Golding
- Division of Viral Products, Center of Biologics Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | | | - Catherine Pilgrim-Grayson
- Division of Urology, Obstetrics, and Gynecology, Office of Rare Diseases, Pediatrics, Urologic and Reproductive Medicine and Office of New Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Leah Berhane
- Division of Urology, Obstetrics, and Gynecology, Office of Rare Diseases, Pediatrics, Urologic and Reproductive Medicine and Office of New Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Andrea L. Cox
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Bloomberg Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Irina Burd
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Andrew Pekosz
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Heba H. Mostafa
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Eili Y. Klein
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Center for Disease Dynamics, Economics, and Policy, United Nations Office for Disease Risk Reduction, Washington DC, USA
| | - Sabra L. Klein
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Cui J, Heavey J, Lin L, Klein EY, Madden GR, Sifri CD, Lewis B, Vullikanti AK, Prakash BA. Modeling relaxed policies for discontinuation of methicillin-resistant Staphylococcus aureus contact precautions. Infect Control Hosp Epidemiol 2024:1-6. [PMID: 38404133 DOI: 10.1017/ice.2024.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
OBJECTIVE To evaluate the economic costs of reducing the University of Virginia Hospital's present "3-negative" policy, which continues methicillin-resistant Staphylococcus aureus (MRSA) contact precautions until patients receive 3 consecutive negative test results, to either 2 or 1 negative. DESIGN Cost-effective analysis. SETTINGS The University of Virginia Hospital. PATIENTS The study included data from 41,216 patients from 2015 to 2019. METHODS We developed a model for MRSA transmission in the University of Virginia Hospital, accounting for both environmental contamination and interactions between patients and providers, which were derived from electronic health record (EHR) data. The model was fit to MRSA incidence over the study period under the current 3-negative clearance policy. A counterfactual simulation was used to estimate outcomes and costs for 2- and 1-negative policies compared with the current 3-negative policy. RESULTS Our findings suggest that 2-negative and 1-negative policies would have led to 6 (95% CI, -30 to 44; P < .001) and 17 (95% CI, -23 to 59; -10.1% to 25.8%; P < .001) more MRSA cases, respectively, at the hospital over the study period. Overall, the 1-negative policy has statistically significantly lower costs ($628,452; 95% CI, $513,592-$752,148) annually (P < .001) in US dollars, inflation-adjusted for 2023) than the 2-negative policy ($687,946; 95% CI, $562,522-$812,662) and 3-negative ($702,823; 95% CI, $577,277-$846,605). CONCLUSIONS A single negative MRSA nares PCR test may provide sufficient evidence to discontinue MRSA contact precautions, and it may be the most cost-effective option.
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Affiliation(s)
- Jiaming Cui
- College of Computing, Georgia Institute of Technology, Atlanta, Georgia
| | - Jack Heavey
- Department of Computer Science, University of Virginia, Charlottesville, Virginia
| | - Leo Lin
- Department of Computer Science, University of Virginia, Charlottesville, Virginia
| | - Eili Y Klein
- Center for Disease Dynamics, Economics & Policy, Washington, DC
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Gregory R Madden
- Division of Infectious Diseases & International Health, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Costi D Sifri
- Division of Infectious Diseases & International Health, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia
- Office of Hospital Epidemiology/Infection Prevention & Control, UVA Health, Charlottesville, Virginia
| | - Bryan Lewis
- Biocomplexity Institute, University of Virginia, Charlottesville, Virginia
| | - Anil K Vullikanti
- Department of Computer Science, University of Virginia, Charlottesville, Virginia
- Biocomplexity Institute, University of Virginia, Charlottesville, Virginia
| | - B Aditya Prakash
- College of Computing, Georgia Institute of Technology, Atlanta, Georgia
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Cherian JP, Helsel TN, Jones GF, Virk Z, Salinas A, Grieb SM, Klein EY, Tamma PD, Cosgrove SE. Understanding the role of antibiotic-associated adverse events in influencing antibiotic decision-making. Antimicrob Steward Healthc Epidemiol 2024; 4:e13. [PMID: 38415083 PMCID: PMC10897715 DOI: 10.1017/ash.2024.2] [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] [Received: 10/12/2023] [Revised: 12/05/2023] [Accepted: 12/11/2023] [Indexed: 02/29/2024]
Abstract
Objective To (1) understand the role of antibiotic-associated adverse events (ABX-AEs) on antibiotic decision-making, (2) understand clinician preferences for ABX-AE feedback, and (3) identify ABX-AEs of greatest clinical concern. Design Focus groups. Setting Academic medical center. Participants Medical and surgical house staff, attending physicians, and advanced practice practitioners. Methods Focus groups were conducted from May 2022 to December 2022. Participants discussed the role of ABX-AEs in antibiotic decision-making and feedback preferences and evaluated the prespecified categorization of ABX-AEs based on degree of clinical concern. Thematic analysis was conducted using inductive coding. Results Four focus groups were conducted (n = 15). Six themes were identified. (1) ABX-AE risks during initial prescribing influence the antibiotic prescribed rather than the decision of whether to prescribe. (2) The occurrence of an ABX-AE leads to reassessment of the clinical indication for antibiotic therapy. (3) The impact of an ABX-AE on other management decisions is as important as the direct harm of the ABX-AE. (4) ABX-AEs may be overlooked because of limited feedback regarding the occurrence of ABX-AEs. (5) Clinicians are receptive to feedback regarding ABX-AEs but are concerned about it being punitive. (6) Feedback must be curated to prevent clinicians from being overwhelmed with data. Clinicians generally agreed with the prespecified categorizations of ABX-AEs by degree of clinical concern. Conclusions The themes identified and assessment of ABX-AEs of greatest clinical concern may inform antibiotic stewardship initiatives that incorporate reporting of ABX-AEs as a strategy to reduce unnecessary antibiotic use.
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Affiliation(s)
- Jerald P. Cherian
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Taylor N. Helsel
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - George F. Jones
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Zunaira Virk
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alejandra Salinas
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Suzanne M. Grieb
- Department of Pediatrics, Center for Child and Community Health Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Eili Y. Klein
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Pranita D. Tamma
- Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sara E. Cosgrove
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Ehmann MR, Klein EY, Zhao X, Mitchell J, Menez S, Smith A, Levin S, Hinson JS. Epidemiology and Clinical Outcomes of Community-Acquired Acute Kidney Injury in the Emergency Department: A Multisite Retrospective Cohort Study. Am J Kidney Dis 2023:S0272-6386(23)00945-9. [PMID: 38072210 DOI: 10.1053/j.ajkd.2023.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 09/26/2023] [Accepted: 10/07/2023] [Indexed: 02/02/2024]
Abstract
RATIONALE & OBJECTIVE The prevalence of community-acquired acute kidney injury (CA-AKI) in the United States and its clinical consequences are not well described. Our objective was to describe the epidemiology of CA-AKI and the associated clinical outcomes. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS 178,927 encounters by 139,632 adults at 5 US emergency departments (EDs) between July 1, 2017, and December 31, 2022. PREDICTORS CA-AKI identified using KDIGO (Kidney Disease: Improving Global Outcomes) serum creatinine (Scr)-based criteria. OUTCOMES For encounters resulting in hospitalization, the in-hospital trajectory of AKI severity, dialysis initiation, intensive care unit (ICU) admission, and death. For all encounters, occurrence over 180 days of hospitalization, ICU admission, new or progressive chronic kidney disease, dialysis initiation, and death. ANALYTICAL APPROACH Multivariable logistic regression analysis to test the association between CA-AKI and measured outcomes. RESULTS For all encounters, 10.4% of patients met the criteria for any stage of AKI on arrival to the ED. 16.6% of patients admitted to the hospital from the ED had CA-AKI on arrival to the ED. The likelihood of AKI recovery was inversely related to CA-AKI stage on arrival to the ED. Among encounters for hospitalized patients, CA-AKI was associated with in-hospital dialysis initiation (OR, 6.2; 95% CI, 5.1-7.5), ICU admission (OR, 1.9; 95% CI, 1.7-2.0), and death (OR, 2.2; 95% CI, 2.0-2.5) compared with patients without CA-AKI. Among all encounters, CA-AKI was associated with new or progressive chronic kidney disease (OR, 6.0; 95% CI, 5.6-6.4), dialysis initiation (OR, 5.1; 95% CI, 4.5-5.7), subsequent hospitalization (OR, 1.1; 95% CI, 1.1-1.2) including ICU admission (OR, 1.2; 95% CI, 1.1-1.4), and death (OR, 1.6; 95% CI, 1.5-1.7) during the subsequent 180 days. LIMITATIONS Residual confounding. Study implemented at a single university-based health system. Potential selection bias related to exclusion of patients without an available baseline Scr measurement. Potential ascertainment bias related to limited repeat Scr data during follow-up after an ED visit. CONCLUSIONS CA-AKI is a common and important entity that is associated with serious adverse clinical consequences during the 6-month period after diagnosis. PLAIN-LANGUAGE SUMMARY Acute kidney injury (AKI) is a condition characterized by a rapid decline in kidney function. There are many causes of AKI, but few studies have examined how often AKI is already present when patients first arrive to an emergency department seeking medical attention for any reason. We analyzed approximately 175,000 visits to Johns Hopkins emergency departments and found that AKI is common on presentation to the emergency department and that patients with AKI have increased risks of hospitalization, intensive care unit admission, development of chronic kidney disease, requirement of dialysis, and death in the first 6 months after diagnosis. AKI is an important condition for health care professionals to recognize and is associated with serious adverse outcomes.
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Affiliation(s)
- Michael R Ehmann
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland; Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland.
| | - Eili Y Klein
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland; Center for Disease Dynamics, Economics & Policy, Washington, District of Columbia
| | - Xihan Zhao
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jonathon Mitchell
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Steven Menez
- Division of Nephrology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | | | - Scott Levin
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland; Malone Center for Engineering in Healthcare, Johns Hopkins Whiting School of Engineering, Baltimore, Maryland; Beckman Coulter, Brea, California
| | - Jeremiah S Hinson
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland; Malone Center for Engineering in Healthcare, Johns Hopkins Whiting School of Engineering, Baltimore, Maryland; Beckman Coulter, Brea, California
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Garneau WM, Jones JL, Dashler GM, Mostafa HH, Judson SD, Kwon N, Hamill MM, Gilliams EA, Rudolph DS, Keruly JC, Fall A, Klein EY, Hansoti B, Gebo KA. Risk Factors for Hospitalization and Effect of Immunosuppression on Clinical Outcomes Among an Urban Cohort of Patients With Mpox. Open Forum Infect Dis 2023; 10:ofad533. [PMID: 38058459 PMCID: PMC10697423 DOI: 10.1093/ofid/ofad533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 10/30/2023] [Indexed: 12/08/2023] Open
Abstract
Background During the 2022 mpox outbreak most patients were managed as outpatients, but some required hospitalization. Uncontrolled human immunodeficiency virus (HIV) has been identified as a risk factor for severe mpox. Methods Patients with mpox diagnosed or treated within the Johns Hopkins Health System between 1 June and 15 December 2022 were included. The primary outcome of interest was risk of hospitalization. Demographic features, comorbid conditions, treatment, and clinical outcomes were determined. Results A total of 353 patients were tested or treated for mpox; 100 had mpox diagnosed or treated (median age, 35.3 years; 97.0% male; 57.0% black and 10.0% Hispanic; 46.0% people with HIV [PWH]). Seventeen patients (17.0%) required hospitalization, 10 of whom were PWH. Age >40 years, race, ethnicity, HIV status, insurance status, and body mass index >30 (calculated as weight in kilograms divided by height in meters squared) were not associated with hospitalization. Eight of 9 patients (88.9%) with immunosuppression were hospitalized. Immunosuppression was associated with hospitalization in univariate (odds ratio, 69.3 [95% confidence interval, 7.8-619.7]) and adjusted analysis (adjusted odds ratio, 94.8 [8.5-1060.1]). Two patients (11.8%) who were hospitalized required intensive care unit admission and died; both had uncontrolled HIV infection and CD4 T-cell counts <50/µL. Median cycle threshold values for the first positive mpox virus sample did not differ between those who were hospitalized and those who were not. Conclusions Immunosuppression was a significant risk factor for hospitalization with mpox. PWH with CD4 T-cell counts <50/µL are at high risk of death due to mpox infection. Patients who are immunosuppressed should be considered for early and aggressive treatment of mpox, given the increased risk of hospitalization.
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Affiliation(s)
- William M Garneau
- Department of Medicine, Division of Hospital Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joyce L Jones
- Departent of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Gabriella M Dashler
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Heba H Mostafa
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Seth D Judson
- Departent of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nathan Kwon
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Matthew M Hamill
- Departent of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth A Gilliams
- Departent of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David S Rudolph
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jeanne C Keruly
- Departent of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Amary Fall
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Eili Y Klein
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Bhakti Hansoti
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kelly A Gebo
- Departent of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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8
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Keller SC, Hannum SM, Weems K, Oladapo-Shittu O, Salinas AB, Marsteller JA, Gurses AP, Klein EY, Shpitser I, Crnich CJ, Bhanot N, Rock C, Cosgrove SE. Implementing and validating a home-infusion central-line-associated bloodstream infection surveillance definition. Infect Control Hosp Epidemiol 2023; 44:1748-1759. [PMID: 37078467 PMCID: PMC10665867 DOI: 10.1017/ice.2023.70] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 03/13/2023] [Accepted: 03/15/2023] [Indexed: 04/21/2023]
Abstract
OBJECTIVE Central-line-associated bloodstream infection (CLABSI) surveillance in home infusion therapy is necessary to track efforts to reduce infections, but a standardized, validated, and feasible definition is lacking. We tested the validity of a home-infusion CLABSI surveillance definition and the feasibility and acceptability of its implementation. DESIGN Mixed-methods study including validation of CLABSI cases and semistructured interviews with staff applying these approaches. SETTING This study was conducted in 5 large home-infusion agencies in a CLABSI prevention collaborative across 14 states and the District of Columbia. PARTICIPANTS Staff performing home-infusion CLABSI surveillance. METHODS From May 2021 to May 2022, agencies implemented a home-infusion CLABSI surveillance definition, using 3 approaches to secondary bloodstream infections (BSIs): National Healthcare Safety Program (NHSN) criteria, modified NHSN criteria (only applying the 4 most common NHSN-defined secondary BSIs), and all home-infusion-onset bacteremia (HiOB). Data on all positive blood cultures were sent to an infection preventionist for validation. Surveillance staff underwent semistructured interviews focused on their perceptions of the definition 1 and 3-4 months after implementation. RESULTS Interrater reliability scores overall ranged from κ = 0.65 for the modified NHSN criteria to κ = 0.68 for the NHSN criteria to κ = 0.72 for the HiOB criteria. For the NHSN criteria, the agency-determined rate was 0.21 per 1,000 central-line (CL) days, and the validator-determined rate was 0.20 per 1,000 CL days. Overall, implementing a standardized definition was thought to be a positive change that would be generalizable and feasible though time-consuming and labor intensive. CONCLUSIONS The home-infusion CLABSI surveillance definition was valid and feasible to implement.
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Affiliation(s)
- Sara C. Keller
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Armstrong Institute of Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland
| | - Susan M. Hannum
- Department of Health Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Kimberly Weems
- Department of Hospital Epidemiology and Infection Control, Johns Hopkins Health System, Baltimore, Maryland
- Department of Infection Prevention, Nuvance Health Vassar Brothers Medical Center, Poughkeepsie, New York
| | - Opeyemi Oladapo-Shittu
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alejandra B. Salinas
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jill A. Marsteller
- Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Armstrong Institute of Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland
| | - Ayse P. Gurses
- Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Armstrong Institute of Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Malone Center for Engineering in Health Care, Johns Hopkins Whiting School of Engineering, Baltimore, Maryland
| | - Eili Y. Klein
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ilya Shpitser
- Department of Computer Science, Johns Hopkins Whiting School of Engineering, Baltimore, Maryland
| | - Christopher J. Crnich
- Division of Infectious Diseases, Department of Medicine, University of Wisconsin School of Medicine, Madison, Wisconsin
| | - Nitin Bhanot
- Division of Infectious Diseases, Department of Medicine, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Clare Rock
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Armstrong Institute of Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland
- Department of Hospital Epidemiology and Infection Control, Johns Hopkins Health System, Baltimore, Maryland
| | - Sara E. Cosgrove
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Armstrong Institute of Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland
- Department of Hospital Epidemiology and Infection Control, Johns Hopkins Health System, Baltimore, Maryland
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9
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Klein EY, Fall A, Norton JM, Eldesouki RE, Abdullah O, Han L, Yunker M, Mostafa HH. Severity outcomes associated with SARS-CoV-2 XBB variants, an observational analysis. J Clin Virol 2023; 165:105500. [PMID: 37290254 PMCID: PMC10232717 DOI: 10.1016/j.jcv.2023.105500] [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: 03/20/2023] [Revised: 05/19/2023] [Accepted: 05/30/2023] [Indexed: 06/10/2023]
Abstract
The rapidity with which SARS-CoV-2 XBB variants rose to predominance has been alarming. We used a large cohort of patients diagnosed with Omicron infections between September 2022 and mid-February 2023 to evaluate the likelihood of admission or need for supplemental oxygen in patients infected with XBB variants. Our data showed no significant association between XBB or XBB.1.5 infections and admissions. Older age groups, lack of vaccination, immunosuppression and underlying heart, kidney, and lung disease showed significant associations with hospitalization.
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Affiliation(s)
- Eili Y Klein
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA; Department of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, MD, USA; One Health Trust, Washington, DC, USA.
| | - Amary Fall
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Julie M Norton
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Raghda E Eldesouki
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Omar Abdullah
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Lijie Han
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Madeline Yunker
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Heba H Mostafa
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Baltimore, MD, USA
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10
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Smith LL, Fallon SA, Virk ZQ, Salinas AB, Curless MS, Cosgrove SE, Maragakis LL, Rock C, Klein EY. Healthcare personnel interactive pathogen exposure response system. Infect Control Hosp Epidemiol 2023; 44:1358-1360. [PMID: 37114417 DOI: 10.1017/ice.2022.261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
Exposure investigations are labor intensive and vulnerable to recall bias. We developed an algorithm to identify healthcare personnel (HCP) interactions from the electronic health record (EHR), and we evaluated its accuracy against conventional exposure investigations. The EHR algorithm identified every known transmission and used ranking to produce a manageable contact list.
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Affiliation(s)
- Leigh L Smith
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
- The Johns Hopkins Hospital Department of Hospital Epidemiology and Infection Control, Baltimore, Maryland
| | - Susan A Fallon
- The Johns Hopkins Hospital Department of Hospital Epidemiology and Infection Control, Baltimore, Maryland
| | - Zunaira Q Virk
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alejandra B Salinas
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Melanie S Curless
- The Johns Hopkins Hospital Department of Hospital Epidemiology and Infection Control, Baltimore, Maryland
| | - Sara E Cosgrove
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
- The Johns Hopkins Hospital Department of Hospital Epidemiology and Infection Control, Baltimore, Maryland
| | - Lisa L Maragakis
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
- The Johns Hopkins Hospital Department of Hospital Epidemiology and Infection Control, Baltimore, Maryland
| | - Clare Rock
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
- The Johns Hopkins Hospital Department of Hospital Epidemiology and Infection Control, Baltimore, Maryland
| | - Eili Y Klein
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Center for Disease Dynamics, Economics & Policy, Washington, DC
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11
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Cherian JP, Jones GF, Bachina P, Helsel T, Virk Z, Lee JH, Fiawoo S, Salinas A, Dzintars K, O'Shaughnessy E, Gopinath R, Tamma PD, Cosgrove SE, Klein EY. An Electronic Algorithm to Identify Vancomycin-Associated Acute Kidney Injury. Open Forum Infect Dis 2023; 10:ofad264. [PMID: 37383251 PMCID: PMC10296058 DOI: 10.1093/ofid/ofad264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 05/12/2023] [Indexed: 06/30/2023] Open
Abstract
Background The burden of vancomycin-associated acute kidney injury (V-AKI) is unclear because it is not systematically monitored. The objective of this study was to develop and validate an electronic algorithm to identify cases of V-AKI and to determine its incidence. Methods Adults and children admitted to 1 of 5 health system hospitals from January 2018 to December 2019 who received at least 1 dose of intravenous (IV) vancomycin were included. A subset of charts was reviewed using a V-AKI assessment framework to classify cases as unlikely, possible, or probable events. Based on review, an electronic algorithm was developed and then validated using another subset of charts. Percentage agreement and kappa coefficients were calculated. Sensitivity and specificity were determined at various cutoffs, using chart review as the reference standard. For courses ≥48 hours, the incidence of possible or probable V-AKI events was assessed. Results The algorithm was developed using 494 cases and validated using 200 cases. The percentage agreement between the electronic algorithm and chart review was 92.5% and the weighted kappa was 0.95. The electronic algorithm was 89.7% sensitive and 98.2% specific in detecting possible or probable V-AKI events. For the 11 073 courses of ≥48 hours of vancomycin among 8963 patients, the incidence of possible or probable V-AKI events was 14.0%; the V-AKI incidence rate was 22.8 per 1000 days of IV vancomycin therapy. Conclusions An electronic algorithm demonstrated substantial agreement with chart review and had excellent sensitivity and specificity in detecting possible or probable V-AKI events. The electronic algorithm may be useful for informing future interventions to reduce V-AKI.
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Affiliation(s)
- Jerald P Cherian
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - George F Jones
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Preetham Bachina
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Taylor Helsel
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Zunaira Virk
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jae Hyoung Lee
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Suiyini Fiawoo
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Alejandra Salinas
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kate Dzintars
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth O'Shaughnessy
- Division of Anti-Infectives, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Ramya Gopinath
- Division of Anti-Infectives, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Pranita D Tamma
- Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sara E Cosgrove
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Eili Y Klein
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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12
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Martínez DA, Cai J, Lin G, Goodman KE, Paul R, Lessler J, Levin SR, Toerper M, Simner PJ, Milstone AM, Klein EY. Modelling interventions and contact networks to reduce the spread of carbapenem-resistant organisms between individuals in the ICU. J Hosp Infect 2023; 136:1-7. [PMID: 36907332 PMCID: PMC10315994 DOI: 10.1016/j.jhin.2023.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 01/25/2023] [Accepted: 02/03/2023] [Indexed: 03/13/2023]
Abstract
BACKGROUND Contact precautions are widely used to prevent the transmission of carbapenem-resistant organisms (CROs) in hospital wards. However, evidence for their effectiveness in natural hospital environments is limited. OBJECTIVE To determine which contact precautions, healthcare worker (HCW)-patient interactions, and patient and ward characteristics are associated with greater risk of CRO infection or colonization. DESIGN, SETTING AND PARTICIPANTS CRO clinical and surveillance cultures from two high-acuity wards were assessed through probabilistic modelling to characterize a susceptible patient's risk of CRO infection or colonization during a ward stay. User- and time-stamped electronic health records were used to build HCW-mediated contact networks between patients. Probabilistic models were adjusted for patient (e.g. antibiotic administration) and ward (e.g. hand hygiene compliance, environmental cleaning) characteristics. The effects of risk factors were assessed by adjusted odds ratio (aOR) and 95% Bayesian credible intervals (CrI). EXPOSURES The degree of interaction with CRO-positive patients, stratified by whether CRO-positive patients were on contact precautions. MAIN OUTCOMES AND MEASURES The prevalence of CROs and number of new carriers (i.e. incident CRO aquisition). RESULTS Among 2193 ward visits, 126 (5.8%) patients became colonized or infected with CROs. Susceptible patients had 4.8 daily interactions with CRO-positive individuals on contact precautions (vs 1.9 interactions with those not on contact precautions). The use of contact precautions for CRO-positive patients was associated with a reduced rate (7.4 vs 93.5 per 1000 patient-days at risk) and odds (aOR 0.03, 95% CrI 0.01-0.17) of CRO acquisition among susceptible patients, resulting in an estimated absolute risk reduction of 9.0% (95% CrI 7.6-9.2%). Also, carbapenem administration to susceptible patients was associated with increased odds of CRO acquisition (aOR 2.38, 95% CrI 1.70-3.29). CONCLUSIONS AND RELEVANCE In this population-based cohort study, the use of contact precautions for patients colonized or infected with CROs was associated with lower risk of CRO acquisition among susceptible patients, even after adjusting for antibiotic exposure. Further studies that include organism genotyping are needed to confirm these findings.
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Affiliation(s)
- D A Martínez
- School of Industrial Engineering, Pontificia Universidad Católica de Valparaíso, Valparaíso, Chile; Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA; Department of Medicine, Johns Hopkins University, Baltimore, MD, USA.
| | - J Cai
- Department of Applied Mathematics and Statistics, Johns Hopkins University, Baltimore, MD, USA
| | - G Lin
- Center for Disease Dynamics, Economics and Policy, Washington, DC, USA
| | - K E Goodman
- Department of Epidemiology and Public Health, University of Maryland, Baltimore, MD, USA
| | - R Paul
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC, USA
| | - J Lessler
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA; Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - S R Levin
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - M Toerper
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - P J Simner
- Division of Medical Microbiology, Department of Pathology, Johns Hopkins University, Baltimore, MD, USA
| | - A M Milstone
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA; Department of Pediatrics, Johns Hopkins University, Baltimore, MD, USA
| | - E Y Klein
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA; Center for Disease Dynamics, Economics and Policy, Washington, DC, USA; Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
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13
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Shea K, Borchering RK, Probert WJM, Howerton E, Bogich TL, Li SL, van Panhuis WG, Viboud C, Aguás R, Belov AA, Bhargava SH, Cavany SM, Chang JC, Chen C, Chen J, Chen S, Chen Y, Childs LM, Chow CC, Crooker I, Del Valle SY, España G, Fairchild G, Gerkin RC, Germann TC, Gu Q, Guan X, Guo L, Hart GR, Hladish TJ, Hupert N, Janies D, Kerr CC, Klein DJ, Klein EY, Lin G, Manore C, Meyers LA, Mittler JE, Mu K, Núñez RC, Oidtman RJ, Pasco R, Pastore Y Piontti A, Paul R, Pearson CAB, Perdomo DR, Perkins TA, Pierce K, Pillai AN, Rael RC, Rosenfeld K, Ross CW, Spencer JA, Stoltzfus AB, Toh KB, Vattikuti S, Vespignani A, Wang L, White LJ, Xu P, Yang Y, Yogurtcu ON, Zhang W, Zhao Y, Zou D, Ferrari MJ, Pannell D, Tildesley MJ, Seifarth J, Johnson E, Biggerstaff M, Johansson MA, Slayton RB, Levander JD, Stazer J, Kerr J, Runge MC. Multiple models for outbreak decision support in the face of uncertainty. Proc Natl Acad Sci U S A 2023; 120:e2207537120. [PMID: 37098064 PMCID: PMC10160947 DOI: 10.1073/pnas.2207537120] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2023] Open
Abstract
Policymakers must make management decisions despite incomplete knowledge and conflicting model projections. Little guidance exists for the rapid, representative, and unbiased collection of policy-relevant scientific input from independent modeling teams. Integrating approaches from decision analysis, expert judgment, and model aggregation, we convened multiple modeling teams to evaluate COVID-19 reopening strategies for a mid-sized United States county early in the pandemic. Projections from seventeen distinct models were inconsistent in magnitude but highly consistent in ranking interventions. The 6-mo-ahead aggregate projections were well in line with observed outbreaks in mid-sized US counties. The aggregate results showed that up to half the population could be infected with full workplace reopening, while workplace restrictions reduced median cumulative infections by 82%. Rankings of interventions were consistent across public health objectives, but there was a strong trade-off between public health outcomes and duration of workplace closures, and no win-win intermediate reopening strategies were identified. Between-model variation was high; the aggregate results thus provide valuable risk quantification for decision making. This approach can be applied to the evaluation of management interventions in any setting where models are used to inform decision making. This case study demonstrated the utility of our approach and was one of several multimodel efforts that laid the groundwork for the COVID-19 Scenario Modeling Hub, which has provided multiple rounds of real-time scenario projections for situational awareness and decision making to the Centers for Disease Control and Prevention since December 2020.
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Affiliation(s)
- Katriona Shea
- Department of Biology, The Pennsylvania State University, University Park, PA 16802
- Center for Infectious Disease Dynamics, The Pennsylvania State University, University Park, PA 16802
| | - Rebecca K Borchering
- Department of Biology, The Pennsylvania State University, University Park, PA 16802
- Center for Infectious Disease Dynamics, The Pennsylvania State University, University Park, PA 16802
| | - William J M Probert
- Nuffield Department of Medicine, Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford OX3 7LF, United Kingdom
| | - Emily Howerton
- Department of Biology, The Pennsylvania State University, University Park, PA 16802
- Center for Infectious Disease Dynamics, The Pennsylvania State University, University Park, PA 16802
| | - Tiffany L Bogich
- Department of Biology, The Pennsylvania State University, University Park, PA 16802
- Center for Infectious Disease Dynamics, The Pennsylvania State University, University Park, PA 16802
| | - Shou-Li Li
- State Key Laboratory of Grassland Agro-ecosystems, Center for Grassland Microbiome, and College of Pastoral, Agriculture Science and Technology, Lanzhou University, Lanzhou, 73000, People's Republic of China
| | - Willem G van Panhuis
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA 15260
| | - Cecile Viboud
- Fogarty International Center, National Institutes of Health, Bethesda, MD 20892
| | - Ricardo Aguás
- Nuffield Department of Medicine, Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford OX3 7LF, United Kingdom
| | - Artur A Belov
- Office of Biostatistics and Pharmacovigilance, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD 20993
| | | | - Sean M Cavany
- Department of Biological Sciences, University of Notre Dame, Notre Dame, IN 46556
| | - Joshua C Chang
- Epidemiology and Biostatistics Section, Rehabilitation Medicine, Clinical Center, National Institutes of Health, Bethesda, MD 20892
- Mederrata Research Inc, Columbus, OH 43212
| | - Cynthia Chen
- Department of Civil and Environmental Engineering, University of Washington, Seattle, WA 98195
| | - Jinghui Chen
- Department of Computer Science, University of California, Los Angeles, Los Angeles, CA 90095
| | - Shi Chen
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC 28223
- School of Data Science, University of North Carolina at Charlotte, Charlotte, NC 28223
| | - YangQuan Chen
- Mechatronics, Embedded Systems and Automation Laboratory, School of Engineering, University of California, Merced, CA 95343
| | - Lauren M Childs
- Department of Mathematics, Virginia Tech, Blacksburg, VA 24061
| | - Carson C Chow
- Mathematical Biology Section, Laboratory of Biological Modeling, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892
| | | | | | - Guido España
- Department of Biological Sciences, University of Notre Dame, Notre Dame, IN 46556
| | | | - Richard C Gerkin
- School of Life Sciences, Arizona State University, Tempe, AZ 85287
| | | | - Quanquan Gu
- Department of Computer Science, University of California, Los Angeles, Los Angeles, CA 90095
| | - Xiangyang Guan
- Department of Civil and Environmental Engineering, University of Washington, Seattle, WA 98195
| | - Lihong Guo
- School of Mathematics, Jilin University, Changchun, Jilin 130012, People's Republic of China
| | - Gregory R Hart
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, WA 98109
| | - Thomas J Hladish
- Department of Biology, University of Florida, Gainesville, FL 32611
- Emerging Pathogens Institute, University of Florida, Gainesville, FL 32610
| | - Nathaniel Hupert
- Department of Population Health Sciences, Division of Epidemiology, Weill Cornell Medicine, Cornell University, New York, NY 10065
| | - Daniel Janies
- Computational Intelligence to Predict Health and Environmental Risks, University of North Carolina at Charlotte, Charlotte, NC 28223
| | - Cliff C Kerr
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, WA 98109
| | - Daniel J Klein
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, WA 98109
| | - Eili Y Klein
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD 21209
- One Health Trust, Washington, DC 20015
| | - Gary Lin
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD 21209
- One Health Trust, Washington, DC 20015
| | - Carrie Manore
- Los Alamos National Laboratory, Los Alamos, NM 87545
| | - Lauren Ancel Meyers
- Department of Integrative Biology, The University of Texas at Austin, Austin, TX 78712
| | - John E Mittler
- Department of Microbiology, School of Medicine, University of Washington, Seattle, WA 98195
| | - Kunpeng Mu
- Laboratory for the Modeling of Biological and Socio-technical Systems, Network Science Institute, Northeastern University, Boston, MA 02115
| | - Rafael C Núñez
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, WA 98109
| | - Rachel J Oidtman
- Department of Biological Sciences, University of Notre Dame, Notre Dame, IN 46556
| | - Remy Pasco
- Operations Research and Industrial Engineering, The University of Texas at Austin, Austin, TX 78712
| | - Ana Pastore Y Piontti
- Laboratory for the Modeling of Biological and Socio-technical Systems, Network Science Institute, Northeastern University, Boston, MA 02115
| | - Rajib Paul
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC 28223
| | - Carl A B Pearson
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London WC1E 7HT, United Kingdom
- Centre for Mathematical Modelling of Infectious Diseases, London School of Hygiene & Tropical Medicine, London WC1E 7HT, United Kingdom
- South African Department of Science and Innovation - National Research Foundation Centre of Excellence in Epidemiological Modelling and Analysis, Stellenbosch University, Stellenbosch, 7600 South Africa
| | | | - T Alex Perkins
- Department of Biological Sciences, University of Notre Dame, Notre Dame, IN 46556
| | - Kelly Pierce
- Texas Advanced Computing Center, The University of Texas at Austin, Austin, TX 78712
| | | | | | - Katherine Rosenfeld
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, WA 98109
| | | | | | - Arlin B Stoltzfus
- National Institute of Standards and Technology, Gaithersburg, MD 20899
| | - Kok Ben Toh
- School of Natural Resources and Environment, University of Florida, Gainesville, FL 32611
| | - Shashaank Vattikuti
- Mathematical Biology Section, Laboratory of Biological Modeling, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892
| | - Alessandro Vespignani
- Laboratory for the Modeling of Biological and Socio-technical Systems, Network Science Institute, Northeastern University, Boston, MA 02115
| | - Lingxiao Wang
- Department of Computer Science, University of California, Los Angeles, Los Angeles, CA 90095
| | - Lisa J White
- Nuffield Department of Medicine, Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford OX3 7LF, United Kingdom
| | - Pan Xu
- Department of Computer Science, University of California, Los Angeles, Los Angeles, CA 90095
| | | | - Osman N Yogurtcu
- Office of Biostatistics and Pharmacovigilance, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD 20993
| | - Weitong Zhang
- Department of Computer Science, University of California, Los Angeles, Los Angeles, CA 90095
| | - Yanting Zhao
- The 28th Research Institute of China Technology Group Corporation, Nanjing, Jiangsu 210023, People's Republic of China
| | - Difan Zou
- Department of Computer Science, University of California, Los Angeles, Los Angeles, CA 90095
| | - Matthew J Ferrari
- Department of Biology, The Pennsylvania State University, University Park, PA 16802
- Center for Infectious Disease Dynamics, The Pennsylvania State University, University Park, PA 16802
| | - David Pannell
- School of Agriculture and Environment, University of Western Australia, Perth, WA 6009, Australia
| | - Michael J Tildesley
- Zeeman Institute for Systems Biology and Infectious Disease Epidemiology Research, School of Life Sciences and Mathematics Institute, University of Warwick, Coventry, CV4 7AL, United Kingdom
| | - Jack Seifarth
- Department of Biology, The Pennsylvania State University, University Park, PA 16802
- Center for Infectious Disease Dynamics, The Pennsylvania State University, University Park, PA 16802
| | - Elyse Johnson
- Department of Biology, The Pennsylvania State University, University Park, PA 16802
- Center for Infectious Disease Dynamics, The Pennsylvania State University, University Park, PA 16802
| | - Matthew Biggerstaff
- Centers for Disease Control and Prevention COVID-19 Response, Atlanta, GA 30329
| | - Michael A Johansson
- Centers for Disease Control and Prevention COVID-19 Response, Atlanta, GA 30329
| | - Rachel B Slayton
- Centers for Disease Control and Prevention COVID-19 Response, Atlanta, GA 30329
| | - John D Levander
- Department of Biomedical Informatics, School of Medicine, University of Pittsburgh, PA 15260
| | - Jeff Stazer
- Department of Biomedical Informatics, School of Medicine, University of Pittsburgh, PA 15260
| | - Jessica Kerr
- Department of Biomedical Informatics, School of Medicine, University of Pittsburgh, PA 15260
| | - Michael C Runge
- U.S. Geological Survey, Eastern Ecological Science Center, Laurel, MD 20708
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Cherian J, Cosgrove SE, Haghpanah F, Klein EY. Risk-factor analysis for extended-spectrum beta-lactamase-producing Enterobacterales colonization or infection: Evaluation of a novel approach to assess local prevalence as a risk factor. Infect Control Hosp Epidemiol 2023; 44:1-8. [PMID: 37114753 PMCID: PMC11005063 DOI: 10.1017/ice.2023.76] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
OBJECTIVE To explore an approach to identify the risk of local prevalence of extended-spectrum β-lactamase-producing Enterobacterales (ESBL-E) on ESBL-E colonization or infection and to reassess known risk factors. DESIGN Case-control study. SETTING Johns Hopkins Health System emergency departments (EDs) in the Baltimore-Washington, DC, region. PATIENTS Patients aged ≥18 years with a culture growing Enterobacterales between April 2019 and December 2021. Cases had a culture growing an ESBL-E. METHODS Addresses were linked to Census Block Groups and placed into communities using a clustering algorithm. Prevalence in each community was estimated using the proportion of ESBL-E among Enterobacterales isolates. Logistic regression was used to determine risk factors for ESBL-E colonization or infection. RESULTS ESBL-E were detected in 1,167 of 11,224 patients (10.4%). Risk factors included a history of ESBL-E in the prior 6 months (aOR, 20.67; 95% CI, 13.71-31.18), exposure to a skilled nursing or long-term care facility (aOR, 1.64; 95% CI, 1.37-1.96), exposure to a third-generation cephalosporin (aOR, 1.79; 95% CI, 1.46-2.19), exposure to a carbapenem (aOR, 2.31; 95% CI, 1.68-3.18), or exposure to a trimethoprim-sulfamethoxazole (aOR, 1.54; 95% CI, 1.06-2.25) within the prior 6 months. Patients were at lower risk if their community had a prevalence <25th percentile in the prior 3 months (aOR, 0.83; 95% CI, 0.71-0.98), 6 months (aOR, 0.83; 95% CI, 0.71-0.98), or 12 months (aOR, 0.81; 95% CI, 0.68-0.95). There was no association between being in a community in the >75th percentile and the outcome. CONCLUSIONS This method of defining the local prevalence of ESBL-E may partially capture differences in the likelihood of a patient having an ESBL-E.
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Affiliation(s)
- Jerald Cherian
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sara E. Cosgrove
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Eili Y. Klein
- One Health Trust, Silver Spring, MD, USA
- Department of Emergency Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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St Clair LA, Eldesouki RE, Sachithanandham J, Yin A, Fall A, Morris CP, Norton JM, Forman M, Abdullah O, Dhakal S, Barranta C, Golding H, Bersoff-Matcha SJ, Pilgrim-Grayson C, Berhane L, Cox AL, Burd I, Pekosz A, Mostafa HH, Klein EY, Klein SL. Reduced control of SARS-CoV-2 infection is associated with lower mucosal antibody responses in pregnant women. medRxiv 2023:2023.03.19.23287456. [PMID: 36993216 PMCID: PMC10055594 DOI: 10.1101/2023.03.19.23287456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
Importance Pregnant women are at increased risk of severe COVID-19, but the contribution of viral RNA load, the presence of infectious virus, and mucosal antibody responses remain understudied. Objective To evaluate the association of COVID-19 outcomes following confirmed infection with vaccination status, mucosal antibody responses, infectious virus recovery and viral RNA levels in pregnant compared with non-pregnant women. Design A retrospective observational cohort study of remnant clinical specimens from SARS-CoV-2 infected patients between October 2020-May 2022. Setting Five acute care hospitals within the Johns Hopkins Health System (JHHS) in the Baltimore, MD-Washington, DC area. Participants Participants included confirmed SARS-CoV-2 infected pregnant women and matched non-pregnant women (matching criteria included age, race/ethnicity, and vaccination status). Exposure SARS-CoV-2 infection, with documentation of SARS-CoV-2 mRNA vaccination. Main Outcomes The primary dependent measures were clinical COVID-19 outcomes, infectious virus recovery, viral RNA levels, and mucosal anti-spike (S) IgG titers from upper respiratory tract samples. Clinical outcomes were compared using odds ratios (OR), and measures of virus and antibody were compared using either Fisher's exact test, two-way ANOVA, or regression analyses. Results were stratified according to pregnancy, vaccination status, maternal age, trimester of pregnancy, and infecting SARS-CoV-2 variant. Resultss A total of 452 individuals (117 pregnant and 335 non-pregnant) were included in the study, with both vaccinated and unvaccinated individuals represented. Pregnant women were at increased risk of hospitalization (OR = 4.2; CI = 2.0-8.6), ICU admittance, (OR = 4.5; CI = 1.2-14.2), and of being placed on supplemental oxygen therapy (OR = 3.1; CI =13-6.9). An age-associated decrease in anti-S IgG titer and corresponding increase in viral RNA levels (P< 0.001) was observed in vaccinated pregnant, but not non-pregnant, women. Individuals in their 3rd trimester had higher anti-S IgG titers and lower viral RNA levels (P< 0.05) than those in their 1st or 2nd trimesters. Pregnant individuals experiencing breakthrough infections due to the omicron variant had reduced anti-S IgG compared to non-pregnant women (P< 0.05). Conclusions and Relevance In this cohort study, vaccination status, maternal age, trimester of pregnancy, and infecting SARS-CoV-2 variant were each identified as drivers of differences in mucosal anti-S IgG responses in pregnant compared with non-pregnant women. Observed increased severity of COVID-19 and reduced mucosal antibody responses particularly among pregnant participants infected with the Omicron variant suggest that maintaining high levels of SARS-CoV-2 immunity may be important for protection of this at-risk population.
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Affiliation(s)
- Laura A St Clair
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Raghda E Eldesouki
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Medical Genetics Unit, Histology Department, School of Medicine, Suez Canal University, Egypt
| | - Jaiprasath Sachithanandham
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Anna Yin
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Amary Fall
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - C Paul Morris
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD, USA
| | - Julie M Norton
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael Forman
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Omar Abdullah
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Santosh Dhakal
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Caelan Barranta
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Hana Golding
- Division of Viral Products, Center of Biologics Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | | | - Catherine Pilgrim-Grayson
- Division of Urology, Obstetrics, and Gynecology; Office of Rare Diseases, Pediatrics, Urologic and Reproductive Medicine; Office of New Drugs; Center for Drug Evaluation and Research; U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Leah Berhane
- Division of Urology, Obstetrics, and Gynecology; Office of Rare Diseases, Pediatrics, Urologic and Reproductive Medicine; Office of New Drugs; Center for Drug Evaluation and Research; U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Andrea L Cox
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Bloomberg Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Irina Burd
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Andrew Pekosz
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Heba H Mostafa
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Eili Y Klein
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Center for Disease Dynamics, Economics, and Policy, Washington DC, USA
| | - Sabra L Klein
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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16
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Ehmann MR, Mitchell J, Levin S, Smith A, Menez S, Hinson JS, Klein EY. Renal outcomes following intravenous contrast administration in patients with acute kidney injury: a multi-site retrospective propensity-adjusted analysis. Intensive Care Med 2023; 49:205-215. [PMID: 36715705 DOI: 10.1007/s00134-022-06966-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 12/21/2022] [Indexed: 01/31/2023]
Abstract
PURPOSE Evidence of an association between intravenous contrast media (CM) and persistent renal dysfunction is lacking for patients with pre-existing acute kidney injury (AKI). This study was designed to determine the association between intravenous CM administration and persistent AKI in patients with pre-existing AKI. METHODS A retrospective propensity-weighted and entropy-balanced observational cohort analysis of consecutive hospitalized patients ≥ 18 years old meeting Kidney Disease Improving Global Outcomes (KDIGO) creatinine-based criteria for AKI at time of arrival to one of three emergency departments between 7/1/2017 and 6/30/2021 who did or did not receive intravenous CM. Outcomes included persistent AKI at hospital discharge and initiation of dialysis within 180 days of index encounter. RESULTS Our analysis included 14,449 patient encounters, with 12.8% admitted to the intensive care unit (ICU). CM was administered in 18.4% of all encounters. AKI resolved prior to hospital discharge for 69.1%. No association between intravenous CM administration and persistent AKI was observed after unadjusted multivariable logistic regression modeling (OR 1; 95% CI 0.89-1.11), propensity weighting (OR 0.93; 95% CI 0.83-1.05), and entropy balancing (OR 0.94; 95% CI 0.83-1.05). Sub-group analysis in those admitted to the ICU yielded similar results. Initiation of dialysis within 180 days was observed in 5.4% of the cohort. An association between CM administration and increased risk of dialysis within 180 days was not observed. CONCLUSION Among patients with pre-existing AKI, contrast administration was not associated with either persistent AKI at hospital discharge or initiation of dialysis within 180 days. Current consensus recommendations for use of intravenous CM in patients with stable renal disease may also be applied to patients with pre-existing AKI.
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Affiliation(s)
- Michael R Ehmann
- Department of Emergency Medicine, Johns Hopkins School of Medicine, 1830 E. Monument Street, Suite 6-100, Baltimore, MD, 21287, USA.
| | - Jonathon Mitchell
- Department of Emergency Medicine, Johns Hopkins School of Medicine, 1830 E. Monument Street, Suite 6-100, Baltimore, MD, 21287, USA
| | - Scott Levin
- Department of Emergency Medicine, Johns Hopkins School of Medicine, 1830 E. Monument Street, Suite 6-100, Baltimore, MD, 21287, USA
| | - Aria Smith
- Department of Emergency Medicine, Johns Hopkins School of Medicine, 1830 E. Monument Street, Suite 6-100, Baltimore, MD, 21287, USA
| | - Steven Menez
- Division of Nephrology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Jeremiah S Hinson
- Department of Emergency Medicine, Johns Hopkins School of Medicine, 1830 E. Monument Street, Suite 6-100, Baltimore, MD, 21287, USA
| | - Eili Y Klein
- Department of Emergency Medicine, Johns Hopkins School of Medicine, 1830 E. Monument Street, Suite 6-100, Baltimore, MD, 21287, USA
- Center for Disease Dynamics, Economics & Policy, Washington, DC, USA
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17
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Ehmann MR, Hinson JS, Menez S, Smith A, Klein EY, Levin S. Optimal Acute Kidney Injury Algorithm for Detecting Acute Kidney Injury at Emergency Department Presentation. Kidney Med 2023; 5:100588. [PMID: 36860291 PMCID: PMC9969165 DOI: 10.1016/j.xkme.2022.100588] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
- Michael R. Ehmann
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jeremiah S. Hinson
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Steven Menez
- Department of Medicine, Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Aria Smith
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Eili Y. Klein
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
- Center for Disease Dynamics, Economics and Policy, Washington, District of Columbia
| | - Scott Levin
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
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18
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Hamilton A, Poleon S, Cherian J, Cosgrove SE, Laxminarayan R, Klein EY. 1788. COVID-19 and Antibiotic Prescriptions in the United States: A County-level Analysis. Open Forum Infect Dis 2022. [PMCID: PMC9752833 DOI: 10.1093/ofid/ofac492.1418] [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] [Indexed: 12/23/2022] Open
Abstract
Background Declines in outpatient antibiotic prescribing were reported during the beginning of the COVID-19 pandemic in the United States; however, the overall impact of COVID-19 cases on antibiotic prescribing remains unclear. Methods We conducted an observational, ecological study to assess the impact of COVID-19 cases and pandemic-related, non-pharmaceutical interventions (NPIs) (e.g., school closures and facemasks) on antibiotic prescribing from February to December 2020 in the US. A random effects panel regression of county-level monthly reported COVID-19 case data and corresponding systemic antibiotic prescription data from IQVIA was used. The model controlled for county demographics, NPIs, and prior years’ prescribing. Results Total antibiotic prescriptions fell 26.1% between March and December 2020 compared to this period from 2017 to 2019. Prescribing rates dropped most among children (Figure 1). A 1% increase in county-level monthly COVID-19 cases was associated with a 0.9% increase (95% CI 0.7%, 1.1%; p< 0.01) in monthly prescriptions dispensed to adults and a 1.2% decrease (95% CI -1.7%, -0.8%; p< 0.01) in prescriptions dispensed to children (Table 1). Counties with schools open for in-person instruction were associated with a 4.4% increase (95% CI 2.3%, 6.4%; p< 0.01) in prescriptions among children compared to counties that closed schools. Internal movement restrictions and requiring facemasks were also associated with lower prescribing among children.
A) Total prescriptions per 100,000 population by month (2017-2020). B) Mean prescriptions per 100,000 population for seven age groups (2017-2019 vs 2020). ![]() ![]() Conclusion Though the number of antibiotic prescriptions in 2020 was lower than previous years, the positive association of COVID-19 cases with prescribing for adults and the negative association for children indicates increases in prescribing occurred primarily among adults. The rarity of bacterial co-infection in COVID-19 patients suggests a large fraction of these prescriptions may have been inappropriate. Facemasks and school closures were correlated with reductions in prescribing among children, likely due to the prevention of other upper respiratory infections (e.g., the cold and influenza). Despite reductions, the strongest predictors of prescribing were prior years’ prescribing trends, suggesting the possibility that behavioral norms are an important driver of prescribing practices. Disclosures Sara E. Cosgrove, MD, Basilea: Member of Infection Adjudication Committee Ramanan Laxminarayan, PhD, HealthCubed: Board Member|HealthCubed: Ownership Interest.
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Affiliation(s)
- Alisa Hamilton
- Center for Disease Dynamics, Economics & Policy, Washington, District of Columbia
| | - Suprena Poleon
- Center for Disease Dynamics, Economics & Policy, Washington, District of Columbia
| | - Jerald Cherian
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sara E Cosgrove
- Johns Hopkins University Department of Medicine, Baltimore, Maryland
| | - Ramanan Laxminarayan
- Center for Disease Dynamics, Economics & Policy, Washington, District of Columbia
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19
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Haghpanah F, Hamilton A, Klein EY. 2319. Analysis of the potential impact of effectiveness and availability of mRNA influenza vaccine on hospitalization and mortality. Open Forum Infect Dis 2022. [PMCID: PMC9752400 DOI: 10.1093/ofid/ofac492.150] [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: 12/23/2022] Open
Abstract
Background Influenza viruses constantly change because of antigenic drift. Due to the time currently needed to develop and distribute flu shots, vaccines are often ill-matched to circulating influenza strains. One silver lining of the COVID-19 pandemic was the acceleration of mRNA technology, which could significantly reduce the timeline between strain choice and deployment, potentially increasing vaccine efficacy. Significant private and public investments would be required to accommodate accelerated vaccine development and approval. Hence, it is important to understand the potential impact of mRNA technology on influenza hospitalizations and mortality. Methods We developed a compartmental model stratified by age group to evaluate the potential effect of increased vaccine effectiveness (defined as a two-level measure of protection against infection and hospitalization) on influenza hospitalizations and mortality in the United States. We assume that mRNA technology can only shorten the time from strain choice to distribution but not distribution and administration. Thus, later decisions on vaccine composition would increase effectiveness but reduce availability. To assess this tradeoff, we evaluated two scenarios where strain choice was delayed until summer resulting in a more effective vaccine: (1) available to all age groups in the fall, or (2) available by August but only for adults 65 years and older. Results Assuming current vaccine coverage rates, if not available until October, the vaccine would need a minimum of 80% effectiveness against infection to see a decrease in hospitalizations and deaths (Figures 1A and 1B). When delayed until November, even a 100% effective vaccine could not reduce hospitalizations or deaths (Figures 1C and 1D). For the elderly, a 50% effective vaccine against infection (Figures 1E and 1F) or a vaccine 40% effective against infection and 60% against hospitalization available in late summer was similar to an 80% effective vaccine available in October for all ages.
Age-stratified weekly number of influenza-associated hospitalization per 100,000 population and total number of deaths in the United States for an mRNA vaccine that would be available in either October (A and B), November (C and D), or by late summer but only for the 65+ age group (E and F). The Baseline represents the 10-year average weekly hospitalization rate and mortality during the Flu Season (October to May). Conclusion As the majority of influenza-associated hospitalizations and deaths are in adults 65 years and older, a combination policy targeting higher vaccine effectiveness for this age group in the short term would be the most efficacious. Disclosures All Authors: No reported disclosures.
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Affiliation(s)
- Fardad Haghpanah
- The Center for Disease Dynamics, Economics & Policy, Towson, Maryland
| | - Alisa Hamilton
- Center for Disease Dynamics, Economics & Policy, Washington, District of Columbia
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20
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Morris CP, Eldesouki RE, Sachithanandham J, Fall A, Norton JM, Abdullah O, Gallagher N, Li M, Pekosz A, Klein EY, Mostafa HH. Omicron Subvariants: Clinical, Laboratory, and Cell Culture Characterization. Clin Infect Dis 2022; 76:1276-1284. [PMID: 36366857 PMCID: PMC10069846 DOI: 10.1093/cid/ciac885] [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: 09/12/2022] [Revised: 10/25/2022] [Accepted: 11/08/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
The variant of concern, Omicron, has become the sole circulating SARS-CoV-2 variant for the past several months. Omicron subvariants BA.1, BA.2, BA.3, BA.4, and BA.5 evolved over the time, with BA.1 causing the largest wave of infections globally in December 2021- January 2022. In this study, we compare the clinical outcomes in patients infected with different Omicron subvariants and compare the relative viral loads, and recovery of infectious virus from upper respiratory specimens.
Methods
SARS-CoV-2 positive remnant clinical specimens, diagnosed at the Johns Hopkins Microbiology Laboratory between December 2021 and July 2022, were used for whole genome sequencing. The clinical outcomes of infections with Omicron subvariants were compared to infections with BA.1. Cycle threshold values (Ct) and the recovery of infectious virus on VeroTMPRSS2 cell line from clinical specimens were compared.
Results
The BA.1 was associated with the largest increase in SARS-CoV-2 positivity rate and COVID-19 related hospitalizations at the Johns Hopkins system. After a peak in January, cases fell in the spring, but the emergence of BA.2.12.1 followed by BA.5 in May 2022 led to an increase in case positivity and admissions. BA.1 infections had a lower mean Ct when compared to other Omicron subvariants. BA.5 samples had a greater likelihood of having infectious virus at Ct values less than 20.
Conclusions
Omicron subvariants continue to be associated with a relatively high rate of PCR positivity and hospital admissions. The BA.5 infections are more while BA.2 infections are less likely to have infectious virus, suggesting potential differences in infectibility during the Omicron waves.
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Affiliation(s)
- C Paul Morris
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology , Baltimore, MD , USA
- National Institute of Allergy and Infectious Disease, National Institutes of Health , Rockville, Maryland , USA
| | - Raghda E Eldesouki
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology , Baltimore, MD , USA
- Suez Canal University, School of Medicine, Department of Histology, Genetics unit , Ismailia , Egypt
| | - Jaiprasath Sachithanandham
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, The Johns Hopkins Bloomberg School of Public Health , Baltimore, MD , USA
| | - Amary Fall
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology , Baltimore, MD , USA
| | - Julie M Norton
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology , Baltimore, MD , USA
| | - Omar Abdullah
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology , Baltimore, MD , USA
| | - Nicholas Gallagher
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology , Baltimore, MD , USA
| | - Maggie Li
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, The Johns Hopkins Bloomberg School of Public Health , Baltimore, MD , USA
| | - Andrew Pekosz
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, The Johns Hopkins Bloomberg School of Public Health , Baltimore, MD , USA
- Department of Emergency Medicine, Johns Hopkins School of Medicine , Baltimore, MD , USA
| | - Eili Y Klein
- Department of Emergency Medicine, Johns Hopkins School of Medicine , Baltimore, MD , USA
- Center for Disease Dynamics, Economics, and Policy , Washington DC , USA
| | - Heba H Mostafa
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology , Baltimore, MD , USA
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21
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Morris CP, Eldesouki RE, Fall A, Gaston DC, Norton JM, Gallagher ND, Luo CH, Abdullah O, Klein EY, Mostafa HH. SARS-CoV-2 reinfections during the Delta and Omicron waves. JCI Insight 2022; 7:e162007. [PMID: 36048527 PMCID: PMC9714778 DOI: 10.1172/jci.insight.162007] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 08/31/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUNDIncreased SARS-CoV-2 reinfection rates have been reported recently, with some locations basing reinfection on a second positive PCR test at least 90 days after initial infection. In this study, we used Johns Hopkins SARS-CoV-2 genomic surveillance data to evaluate the frequency of sequencing-validated, confirmed, and inferred reinfections between March 2020 and July 2022.METHODSPatients who had 2 or more positive SARS-CoV-2 tests in our system, with samples sequenced as a part of our surveillance efforts, were identified as the cohort for our study. SARS-CoV-2 genomes of patients' initial and later samples were compared.RESULTSA total of 755 patients (920 samples) had a positive test at least 90 days after the initial test, with a median time between tests of 377 days. Sequencing was attempted on 231 samples and was successful in 127. Rates of successful sequencing spiked during the Omicron surge; there was a higher median number of days from initial infection in these cases compared with those with failed sequences. A total of 122 (98%) patients showed evidence of reinfection; 45 of these patients had sequence-validated reinfection and 77 had inferred reinfections (later sequencing showed a clade that was not circulating when the patient was initially infected). Of the 45 patients with sequence-validated reinfections, 43 (96%) had reinfections that were caused by the Omicron variant, 41 (91%) were symptomatic, 32 (71%) were vaccinated prior to the second infection, 6 (13%) were immunosuppressed, and only 2 (4%) were hospitalized.CONCLUSIONSequence-validated reinfections increased with the Omicron surge but were generally associated with mild infections.FUNDINGFunding was provided by the Johns Hopkins Center of Excellence in Influenza Research and Surveillance (HHSN272201400007C), CDC (75D30121C11061), Johns Hopkins University President's Fund Research Response, Johns Hopkins Department of Pathology, and the Maryland Department of Health.
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Affiliation(s)
- C. Paul Morris
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- National Institute of Allergy and Infectious Disease, NIH, Bethesda, Maryland, USA
| | - Raghda E. Eldesouki
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Genetics Unit, Histology Department, School of Medicine, Suez Canal University, Ismailia, Egypt
| | - Amary Fall
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - David C. Gaston
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Julie M. Norton
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Nicholas D. Gallagher
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Chun Huai Luo
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Omar Abdullah
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Eili Y. Klein
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Center for Disease Dynamics, Economics, and Policy, Washington, DC, USA
| | - Heba H. Mostafa
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Morris CP, Eldesouki RE, Sachithanandham J, Fall A, Norton JM, Abdullah O, Gallagher N, Li M, Pekosz A, Klein EY, Mostafa HH. Omicron Subvariants: Clinical, Laboratory, and Cell Culture Characterization. medRxiv 2022:2022.09.20.22280154. [PMID: 36172137 PMCID: PMC9516865 DOI: 10.1101/2022.09.20.22280154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background The variant of concern, Omicron, has become the sole circulating SARS-CoV-2 variant for the past several months. Omicron subvariants BA.1, BA.2, BA.3, BA.4, and BA.5 evolved over the time, with BA.1 causing the largest wave of infections globally in December 2021- January 2022. In this study, we compare the clinical outcomes in patients infected with different Omicron subvariants and compare the relative viral loads, and recovery of infectious virus from upper respiratory specimens. Methods SARS-CoV-2 positive remnant clinical specimens, diagnosed at the Johns Hopkins Microbiology Laboratory between December 2021 and July 2022, were used for whole genome sequencing. The clinical outcomes of infections with Omicron subvariants were compared to infections with BA.1. Cycle threshold values (Ct) and the recovery of infectious virus on VeroTMPRSS2 cell line from clinical specimens were compared. Results The BA.1 was associated with the largest increase in SARS-CoV-2 positivity rate and COVID-19 related hospitalizations at the Johns Hopkins system. After a peak in January cases fell in the spring, but the emergence of BA.2.12.1 followed by BA.5 in May 2022 led to an increase in case positivity and admissions. BA.1 infections had a lower mean Ct when compared to other Omicron subvariants. BA.5 samples had a greater likelihood of having infectious virus at Ct values less than 20. Conclusions Omicron subvariants continue to associate with a relatively high positivity and admissions. The BA.5 infections are more while BA.2 infections are less likely to have infectious virus, suggesting potential differences in infectibility during the Omicron waves. Funding Centers for Disease Control and Prevention contract 75D30121C11061, NIH/NIAID Center of Excellence in Influenza Research and Surveillance contract HHS N2772201400007C, Johns Hopkins University, Maryland department of health, and The Modeling Infectious Diseases in Healthcare Network (MInD) under awards U01CK000589.
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Affiliation(s)
- C. Paul Morris
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology
- National Institute of Allergy and Infectious Disease, National Institutes of Health
| | - Raghda E. Eldesouki
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology
- Suez Canal University, School of Medicine, Department of Histology, Genetics unit, Egypt
| | - Jaiprasath Sachithanandham
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, The Johns Hopkins Bloomberg School of Public Health
| | - Amary Fall
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology
| | - Julie M. Norton
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology
| | - Omar Abdullah
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology
| | - Nicholas Gallagher
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology
| | - Maggie Li
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, The Johns Hopkins Bloomberg School of Public Health
| | - Andrew Pekosz
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, The Johns Hopkins Bloomberg School of Public Health
- Department of Emergency Medicine, Johns Hopkins School of Medicine
| | - Eili Y. Klein
- Department of Emergency Medicine, Johns Hopkins School of Medicine
- Center for Disease Dynamics, Economics, and Policy, Washington DC
| | - Heba H. Mostafa
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology
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Huai Luo C, Paul Morris C, Sachithanandham J, Amadi A, Gaston DC, Li M, Swanson NJ, Schwartz M, Klein EY, Pekosz A, Mostafa HH. Infection With the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Delta Variant Is Associated With Higher Recovery of Infectious Virus Compared to the Alpha Variant in Both Unvaccinated and Vaccinated Individuals. Clin Infect Dis 2022; 75:e715-e725. [PMID: 34922338 PMCID: PMC8903351 DOI: 10.1093/cid/ciab986] [Citation(s) in RCA: 53] [Impact Index Per Article: 26.5] [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: 08/23/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variant of concern (VOC) B.1.617.2 (Delta) displaced B.1.1.7 (Alpha) and is associated with increases in coronavirus disease 2019 (COVID-19) cases, greater transmissibility, and higher viral RNA loads, but data are lacking regarding the infectious virus load and antiviral antibody levels in the nasal tract. METHODS Whole genome sequencing, cycle threshold (Ct) values, infectious virus, anti-SARS-CoV-2 immunoglobulin G (IgG) levels, and clinical chart reviews were combined to characterize SARS-CoV-2 lineages circulating in the National Capital Region between January and September 2021 and differentiate infections in vaccinated and unvaccinated individuals by the Delta, Alpha, and B.1.2 (the predominant lineage prior to Alpha) variants. RESULTS The Delta variant displaced the Alpha variant to constitute 99% of the circulating lineages in the National Capital Region by August 2021. In Delta infections, 28.5% were breakthrough cases in fully vaccinated individuals compared to 4% in the Alpha infected cohort. Breakthrough infections in both cohorts were associated with comorbidities, but only Delta infections were associated with a significant increase in the median days after vaccination. More than 74% of Delta samples had infectious virus compared to <30% from the Alpha cohort. The recovery of infectious virus with both variants was associated with low levels of local SARS-CoV-2 IgG. CONCLUSIONS Infection with the Delta variant was associated with more frequent recovery of infectious virus in vaccinated and unvaccinated individuals compared to the Alpha variant but was not associated with an increase in disease severity in fully vaccinated individuals. Infectious virus was correlated with the presence of low amounts of antiviral IgG in the nasal specimens.
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Affiliation(s)
- Chun Huai Luo
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - C Paul Morris
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- National Institute of Allergy and Infectious Disease, National Institutes of Health, Washington D.C., USA
| | - Jaiprasath Sachithanandham
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Adannaya Amadi
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - David C Gaston
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Maggie Li
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Nicholas J Swanson
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Matthew Schwartz
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Eili Y Klein
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USAand
- Center for Disease Dynamics, Economics, and Policy, Washington D.C., USA
| | - Andrew Pekosz
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USAand
| | - Heba H Mostafa
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Adams R, Henry KE, Sridharan A, Soleimani H, Zhan A, Rawat N, Johnson L, Hager DN, Cosgrove SE, Markowski A, Klein EY, Chen ES, Saheed MO, Henley M, Miranda S, Houston K, Linton RC, Ahluwalia AR, Wu AW, Saria S. Prospective, multi-site study of patient outcomes after implementation of the TREWS machine learning-based early warning system for sepsis. Nat Med 2022; 28:1455-1460. [PMID: 35864252 DOI: 10.1038/s41591-022-01894-0] [Citation(s) in RCA: 63] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 06/08/2022] [Indexed: 12/20/2022]
Abstract
Early recognition and treatment of sepsis are linked to improved patient outcomes. Machine learning-based early warning systems may reduce the time to recognition, but few systems have undergone clinical evaluation. In this prospective, multi-site cohort study, we examined the association between patient outcomes and provider interaction with a deployed sepsis alert system called the Targeted Real-time Early Warning System (TREWS). During the study, 590,736 patients were monitored by TREWS across five hospitals. We focused our analysis on 6,877 patients with sepsis who were identified by the alert before initiation of antibiotic therapy. Adjusting for patient presentation and severity, patients in this group whose alert was confirmed by a provider within 3 h of the alert had a reduced in-hospital mortality rate (3.3%, confidence interval (CI) 1.7, 5.1%, adjusted absolute reduction, and 18.7%, CI 9.4, 27.0%, adjusted relative reduction), organ failure and length of stay compared with patients whose alert was not confirmed by a provider within 3 h. Improvements in mortality rate (4.5%, CI 0.8, 8.3%, adjusted absolute reduction) and organ failure were larger among those patients who were additionally flagged as high risk. Our findings indicate that early warning systems have the potential to identify sepsis patients early and improve patient outcomes and that sepsis patients who would benefit the most from early treatment can be identified and prioritized at the time of the alert.
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Affiliation(s)
- Roy Adams
- Malone Center for Engineering in Healthcare, Johns Hopkins University, Baltimore, MD, USA.,Department of Psychiatry and Behavioral Science, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Katharine E Henry
- Department of Psychiatry and Behavioral Science, Johns Hopkins School of Medicine, Baltimore, MD, USA.,Department of Computer Science, Johns Hopkins University, Baltimore, MD, USA
| | | | - Hossein Soleimani
- Health Informatics, University of California, San Francisco, CA, USA
| | - Andong Zhan
- Department of Psychiatry and Behavioral Science, Johns Hopkins School of Medicine, Baltimore, MD, USA.,Department of Computer Science, Johns Hopkins University, Baltimore, MD, USA
| | - Nishi Rawat
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Lauren Johnson
- Department of Quality Improvement, Johns Hopkins Hospital, Baltimore, MD, USA
| | - David N Hager
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Sara E Cosgrove
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | | - Eili Y Klein
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Edward S Chen
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Mustapha O Saheed
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Maureen Henley
- Department of Quality Improvement, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Sheila Miranda
- Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Katrina Houston
- Department of Quality Improvement, Johns Hopkins Hospital, Baltimore, MD, USA
| | | | | | - Albert W Wu
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. .,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. .,Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Suchi Saria
- Malone Center for Engineering in Healthcare, Johns Hopkins University, Baltimore, MD, USA. .,Department of Computer Science, Johns Hopkins University, Baltimore, MD, USA. .,Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. .,Bayesian Health, New York, NY, USA.
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Morris CP, Eldesouki RE, Fall A, Gaston DC, Norton JM, Gallagher N, Luo CH, Abdullah O, Klein EY, Mostafa HH. Sequence Proven Reinfections with SARS-CoV-2 at a Large Academic Center. medRxiv 2022:2022.05.17.22275210. [PMID: 35665008 PMCID: PMC9164520 DOI: 10.1101/2022.05.17.22275210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Increased reinfection rates with SARS-CoV-2 have recently been reported, with some locations basing reinfection on a second positive PCR test at least 90 days after initial infection. Methods We identified cases where patients had two positive tests for SARS-CoV-2 and evaluated which of these had been sequenced as part of our surveillance efforts, and evaluated sequencing and clinical data. Results 750 patients (920 samples) had a positive test at least 90 days after the initial test. The median time between tests was 377 days, and 724 (79%) of the post 90-day positives were collected after the emergence of the Omicron variant in November 2021. Sequencing was attempted on 231 samples and successful in 127. Successful sequencing spiked during the Omicron surge and showed higher median days from initial infection compared to failed sequences (median 398 days compared to 276 days, p<0.0005). A total of 122 (98%) patients showed evidence of reinfection, 45 of which had sequence proven reinfection and 77 had inferred reinfections (later sequence showed a clade that was not circulating when the patient was initially infected). Children accounted for only 4% of reinfections. 43 (96%) of 45 infections with sequence proven reinfection were caused by the Omicron variant, 41 (91%) were symptomatic, 32 (71%), were vaccinated prior to the second infection, and 6 (13%) were Immunosuppressed. Only 2 (4%) were hospitalized, and both had underlying conditions. Conclusion Sequence proven reinfections increased with the Omicron variant but generally caused mild infections.
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Affiliation(s)
- C. Paul Morris
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Baltimore, MD, USA
- National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD, USA
| | - Raghda E. Eldesouki
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Genetics Unit Histology Department, School of Medicine, Suez Canal University, Egypt
| | - Amary Fall
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - David C. Gaston
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Julie M. Norton
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Nicholas Gallagher
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Chun Huai Luo
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Omar Abdullah
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Eili Y. Klein
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Center for Disease Dynamics, Economics, and Policy, Washington DC
| | - Heba H. Mostafa
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Baltimore, MD, USA
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Fall A, Eldesouki RE, Sachithanandham J, Morris CP, Norton JM, Gaston DC, Forman M, Abdullah O, Gallagher N, Li M, Swanson NJ, Pekosz A, Klein EY, Mostafa HH. The displacement of the SARS-CoV-2 variant Delta with Omicron: An investigation of hospital admissions and upper respiratory viral loads. EBioMedicine 2022; 79:104008. [PMID: 35460989 PMCID: PMC9020587 DOI: 10.1016/j.ebiom.2022.104008] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [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: 01/31/2022] [Revised: 03/31/2022] [Accepted: 03/31/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The increase in SARS-CoV-2 infections in December 2021 was driven primarily by the Omicron variant, which largely displaced the Delta over a three-week span. Outcomes from infection with Omicron remain uncertain. We evaluated whether clinical outcomes and viral loads differed between Delta and Omicron infections during the period when both variants were co-circulating. METHODS In this retrospective observational cohort study, remnant clinical specimens, positive for SARS-CoV-2 after standard of care testing at the Johns Hopkins Microbiology Laboratory, between the last week of November and the end of December 2021, were used for whole viral genome sequencing. Cycle threshold values (Ct) for viral RNA, the presence of infectious virus, and levels of respiratory IgG were measured, and clinical outcomes were obtained. Differences in each measure were compared between variants stratified by vaccination status. FINDINGS The Omicron variant displaced Delta during the study period and constituted 95% of the circulating lineages by the end of December 2021. Patients with Omicron infections (N = 1,119) were more likely to be vaccinated compared to patients with Delta (N = 908), but were less likely to be admitted (0.33 CI 0.21-0.52), require ICU level care (0.38 CI 0.17-0.87), or succumb to infection (0.26 CI 0.06-1.02) regardless of vaccination status. There was no statistically significant difference in Ct values based on the lineage regardless of the vaccination status. Recovery of infectious virus in cell culture was reduced in boosted patients compared to fully vaccinated without a booster and unvaccinated when infected with the Delta lineage. However, in patients with Omicron infections, recovery of infectious virus was not affected by vaccination. INTERPRETATION Compared to Delta, Omicron was more likely to cause breakthrough infections of vaccinated individuals, yet admissions were less frequent. Admitted patients might develop severe disease comparable to Delta. Efforts for reducing Omicron transmission are required as, though the admission risk might be lower, the increased numbers of infections cause large numbers of hospitalizations. FUNDING NIH/NIAID Center of Excellence in Influenza Research and Surveillance contract HHS N2772201400007C, Johns Hopkins University, Maryland department of health, Centers for Disease Control and Prevention contract 75D30121C11061, and The Modeling Infectious Diseases in Healthcare Network (MInD) under awards U01CK000589.
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Affiliation(s)
- Amary Fall
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Meyer B-121F, 600 N. Wolfe St, Baltimore, MD 21287, USA
| | - Raghda E Eldesouki
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Meyer B-121F, 600 N. Wolfe St, Baltimore, MD 21287, USA
| | - Jaiprasath Sachithanandham
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, The Johns Hopkins Bloomberg School of Public Health, USA
| | - C Paul Morris
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Meyer B-121F, 600 N. Wolfe St, Baltimore, MD 21287, USA; National Institute of Allergy and Infectious Disease, National Institutes of Health, 615 North Wolfe Street, rm W2116, Bethesda, MD 20892, USA
| | - Julie M Norton
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Meyer B-121F, 600 N. Wolfe St, Baltimore, MD 21287, USA
| | - David C Gaston
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Meyer B-121F, 600 N. Wolfe St, Baltimore, MD 21287, USA
| | - Michael Forman
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Meyer B-121F, 600 N. Wolfe St, Baltimore, MD 21287, USA
| | - Omar Abdullah
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Meyer B-121F, 600 N. Wolfe St, Baltimore, MD 21287, USA
| | - Nicholas Gallagher
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Meyer B-121F, 600 N. Wolfe St, Baltimore, MD 21287, USA
| | - Maggie Li
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, The Johns Hopkins Bloomberg School of Public Health, USA
| | - Nicholas J Swanson
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, The Johns Hopkins Bloomberg School of Public Health, USA
| | - Andrew Pekosz
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, The Johns Hopkins Bloomberg School of Public Health, USA; Department of Emergency Medicine, Johns Hopkins School of Medicine, 5801 Smith Ave, Davis Suite 3220, Baltimore, MD 21209, USA.
| | - Eili Y Klein
- Department of Emergency Medicine, Johns Hopkins School of Medicine, 5801 Smith Ave, Davis Suite 3220, Baltimore, MD 21209, USA; Center for Disease Dynamics, Economics, and Policy, Washington DC, USA.
| | - Heba H Mostafa
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Meyer B-121F, 600 N. Wolfe St, Baltimore, MD 21287, USA.
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Morris CP, Luo CH, Sachithanandham J, Li M, Schwartz M, Gaston DC, Gniazdowski V, Giraldo-Castillo N, Amadi A, Norton JM, Wright WF, Klein EY, Pekosz A, Mostafa HH. Large Scale SARS-CoV-2 Molecular Testing and Genomic Surveillance Reveal Prolonged Infections, Protracted RNA shedding, and Viral Reinfections. Front Cell Infect Microbiol 2022; 12:809407. [PMID: 35480235 PMCID: PMC9035932 DOI: 10.3389/fcimb.2022.809407] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 03/15/2022] [Indexed: 12/22/2022] Open
Abstract
Large-scale SARS-CoV-2 molecular testing coupled with whole genome sequencing in the diagnostic laboratories is instrumental for real-time genomic surveillance. The extensive genomic, laboratory, and clinical data provide a valuable resource for understanding cases of reinfection versus prolonged RNA shedding and protracted infections. In this study, data from a total of 22,292 clinical specimens, positive by SARS-CoV-2 molecular diagnosis at Johns Hopkins clinical virology laboratory between March 11th 2020 to September 23rd 2021, were used to identify patients with two or more positive results. A total of 3,650 samples collected from 1,529 patients who had between 2 and 20 positive results were identified in a time frame that extended up to 403 days from the first positive. Cycle threshold values (Ct) were available for 1,622 samples, the median of which was over 30 by 11 days after the first positive. Extended recovery of infectious virus on cell culture was notable for up to 70 days after the first positive in immunocompromised patients. Whole genome sequencing data generated as a part of our SARS-CoV-2 genomic surveillance was available for 1,027 samples from patients that had multiple positive tests. Positive samples collected more than 10 days after initial positive with high quality sequences (coverage >90% and mean depth >100), were more likely to be from unvaccinated, or immunosuppressed patients. Reinfections with viral variants of concern were found in 3 patients more than 130 days from prior infections with a different viral clade. In 75 patients that had 2 or more high quality sequences, the acquisition of more substitutions or deletions was associated with lack of vaccination and longer time between the recovered viruses. Our study highlights the value of integrating genomic, laboratory, and clinical data for understanding the biology of SARS-CoV-2 as well as for setting a precedent for future epidemics and pandemics.
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Affiliation(s)
- C. Paul Morris
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Baltimore, MD, United States
- National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD, United States
| | - Chun Huai Luo
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Jaiprasath Sachithanandham
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Maggie Li
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Matthew Schwartz
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - David C. Gaston
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Victoria Gniazdowski
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Nicolas Giraldo-Castillo
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Adannaya Amadi
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Julie M. Norton
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - William F. Wright
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Eili Y. Klein
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States
- Center for Disease Dynamics, Economics, and Policy, Washington, DC, United States
| | - Andrew Pekosz
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Heba H. Mostafa
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Baltimore, MD, United States
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Çaǧlayan Ç, Barnes SL, Pineles LL, Harris AD, Klein EY. A Data-Driven Framework for Identifying Intensive Care Unit Admissions Colonized With Multidrug-Resistant Organisms. Front Public Health 2022; 10:853757. [PMID: 35372195 PMCID: PMC8968755 DOI: 10.3389/fpubh.2022.853757] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 02/14/2022] [Indexed: 12/29/2022] Open
Abstract
Background The rising prevalence of multi-drug resistant organisms (MDROs), such as Methicillin-resistant Staphylococcus aureus (MRSA), Vancomycin-resistant Enterococci (VRE), and Carbapenem-resistant Enterobacteriaceae (CRE), is an increasing concern in healthcare settings. Materials and Methods Leveraging data from electronic healthcare records and a unique MDRO universal screening program, we developed a data-driven modeling framework to predict MRSA, VRE, and CRE colonization upon intensive care unit (ICU) admission, and identified the associated socio-demographic and clinical factors using logistic regression (LR), random forest (RF), and XGBoost algorithms. We performed threshold optimization for converting predicted probabilities into binary predictions and identified the cut-off maximizing the sum of sensitivity and specificity. Results Four thousand six hundred seventy ICU admissions (3,958 patients) were examined. MDRO colonization rate was 17.59% (13.03% VRE, 1.45% CRE, and 7.47% MRSA). Our study achieved the following sensitivity and specificity values with the best performing models, respectively: 80% and 66% for VRE with LR, 73% and 77% for CRE with XGBoost, 76% and 59% for MRSA with RF, and 82% and 83% for MDRO (i.e., VRE or CRE or MRSA) with RF. Further, we identified several predictors of MDRO colonization, including long-term care facility stay, current diagnosis of skin/subcutaneous tissue or infectious/parasitic disease, and recent isolation precaution procedures before ICU admission. Conclusion Our data-driven modeling framework can be used as a clinical decision support tool for timely predictions, characterization and identification of high-risk patients, and selective and timely use of infection control measures in ICUs.
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Affiliation(s)
- Çaǧlar Çaǧlayan
- Asymmetric Operations Sector, Johns Hopkins University Applied Physics Laboratory, Laurel, MD, United States
| | - Sean L. Barnes
- Department of Decision, Operations and Information Technologies (DO&IT), R.H. Smith School of Business, University of Maryland, College Park, MD, United States
| | - Lisa L. Pineles
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Anthony D. Harris
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Eili Y. Klein
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Center for Disease Dynamics, Economics and Policy, Washington, DC, United States
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Mody L, Akinboyo IC, Babcock HM, Bischoff WE, Cheng VCC, Chiotos K, Claeys KC, Coffey KC, Diekema DJ, Donskey CJ, Ellingson KD, Gilmartin HM, Gohil SK, Harris AD, Keller SC, Klein EY, Krein SL, Kwon JH, Lauring AS, Livorsi DJ, Lofgren ET, Merrill K, Milstone AM, Monsees EA, Morgan DJ, Perri LP, Pfeiffer CD, Rock C, Saint S, Sickbert-Bennett E, Skelton F, Suda KJ, Talbot TR, Vaughn VM, Weber DJ, Wiemken TL, Yassin MH, Ziegler MJ, Anderson DJ. Coronavirus disease 2019 (COVID-19) research agenda for healthcare epidemiology. Infect Control Hosp Epidemiol 2022; 43:156-166. [PMID: 33487199 PMCID: PMC8160487 DOI: 10.1017/ice.2021.25] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 01/07/2021] [Indexed: 02/07/2023]
Abstract
This SHEA white paper identifies knowledge gaps and challenges in healthcare epidemiology research related to coronavirus disease 2019 (COVID-19) with a focus on core principles of healthcare epidemiology. These gaps, revealed during the worst phases of the COVID-19 pandemic, are described in 10 sections: epidemiology, outbreak investigation, surveillance, isolation precaution practices, personal protective equipment (PPE), environmental contamination and disinfection, drug and supply shortages, antimicrobial stewardship, healthcare personnel (HCP) occupational safety, and return to work policies. Each section highlights three critical healthcare epidemiology research questions with detailed description provided in supplementary materials. This research agenda calls for translational studies from laboratory-based basic science research to well-designed, large-scale studies and health outcomes research. Research gaps and challenges related to nursing homes and social disparities are included. Collaborations across various disciplines, expertise and across diverse geographic locations will be critical.
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Affiliation(s)
- Lona Mody
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, United States
- Geriatrics Research Education and Clinical Center, Veterans’ Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, United States
| | - Ibukunoluwa C. Akinboyo
- Division of Infectious Diseases, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, United States
| | - Hilary M. Babcock
- Washington University School of Medicine, St. Louis, Missouri, United States
| | - Werner E. Bischoff
- Wake Forest School of Medicine, Winston Salem, North Carolina, United States
| | - Vincent Chi-Chung Cheng
- Department of Microbiology, Queen Mary Hospital, Hong Kong Special Administrative Region, China
- Infection Control Team, Queen Mary Hospital, Hong Kong West Cluster, Hong Kong Special Administrative Region, China
| | - Kathleen Chiotos
- Division of Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Kimberly C. Claeys
- University of Maryland School of Pharmacy, Baltimore, Maryland, United States
| | - K. C. Coffey
- University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - Daniel J. Diekema
- Carver College of Medicine, University of Iowa, Iowa City, Iowa, United States
| | - Curtis J. Donskey
- Infectious Diseases Section, Louis Stokes Cleveland Veterans’ Affairs Medical Center, Cleveland, Ohio, United States
- Case Western Reserve University School of Medicine, Cleveland, Ohio, United States
| | - Katherine D. Ellingson
- Department of Epidemiology and Biostatistics, College of Public Health, University of Arizona, Tucson, Arizona, United States
| | - Heather M. Gilmartin
- Veterans’ Affairs Eastern Colorado Healthcare System, Aurora, Colorado, United States
- Colorado School of Public Health, University of Colorado, Aurora, Colorado, United States
| | - Shruti K. Gohil
- Division of Infectious Diseases, University of California Irvine School of Medicine, Irvine, California, United States
- Epidemiology and Infection Prevention, UC Irvine Health, Irvine, California, United States
| | - Anthony D. Harris
- University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - Sara C. Keller
- Division of Infectious Diseases, John Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Eili Y. Klein
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, Maryland, Unites States
| | - Sarah L. Krein
- Veterans’ Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor, Michigan, United States
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, United States
| | - Jennie H Kwon
- Washington University School of Medicine, St. Louis, Missouri, United States
| | - Adam S. Lauring
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, United States
| | - Daniel J. Livorsi
- Carver College of Medicine, University of Iowa, Iowa City, Iowa, United States
- Iowa City Veterans’ Affairs Health Care System, Iowa City, Iowa, United States
| | - Eric T. Lofgren
- Paul G. Allen School for Global Animal Health, Washington State University, Pullman, Washington, United States
| | | | - Aaron M. Milstone
- Division of Pediatric Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Elizabeth A. Monsees
- Children’s Mercy Kansas City, Kansas City, Missouri, United States
- University of Missouri–Kansas City School of Medicine, Kansas City, Missouri, United States
| | - Daniel J. Morgan
- University of Maryland School of Medicine, Baltimore, Maryland, United States
- Veterans’ Affairs Maryland Healthcare System, Baltimore, Maryland, United States
| | - Luci P. Perri
- Infection Control Results, Wingate, North Carolina, United States
| | - Christopher D. Pfeiffer
- Veterans’ Affairs Portland Health Care System, Portland, Oregon, United States
- Oregon Health & Science University, Portland, Oregon, United States
| | - Clare Rock
- Division of Infectious Diseases, John Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Sanjay Saint
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, United States
- Veterans’ Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, United States
| | - Emily Sickbert-Bennett
- Department of Infection Prevention, University of North Carolina Medical Center, Chapel Hill, North Carolina, United States
| | - Felicia Skelton
- Michael E. DeBakey Veterans’ Affairs Medical Center, Houston, Texas, United States
- H. Ben Taub Department of Physical Medicine & Rehabilitation, Baylor College of Medicine, Houston, Texas, United States
| | - Katie J. Suda
- Center for Health Equity Research and Promotion, Veterans’ Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, United States
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Thomas R. Talbot
- Vanderbilt University School of Medicine, Nashville, Tennessee, United States
| | - Valerie M. Vaughn
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - David J. Weber
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| | - Timothy L. Wiemken
- Division of Infectious Diseases, Allergy, and Immunology, Department of Medicine, Saint Louis University School of Medicine, St Louis, Missouri, United States
| | - Mohamed H. Yassin
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
- Infectious Diseases and Microbiology, Graduate School of Public Health, University of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Matthew J. Ziegler
- Infectious Diseases Division, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Deverick J. Anderson
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University School of Medicine, Durham, North Carolina, United States
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Fall A, Eldesouki RE, Sachithanandham J, Paul Morris C, Norton JM, Gaston DC, Forman M, Abdullah O, Gallagher N, Li M, Swanson NJ, Pekosz A, Klein EY, Mostafa HH. A Quick Displacement of the SARS-CoV-2 variant Delta with Omicron: Unprecedented Spike in COVID-19 Cases Associated with Fewer Admissions and Comparable Upper Respiratory Viral Loads. medRxiv 2022. [PMID: 35118480 PMCID: PMC8811948 DOI: 10.1101/2022.01.26.22269927] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The increase in SARS-CoV-2 infections in December 2021 in the United States was driven primarily by the Omicron variant which largely displaced the Delta over a three week span. Outcomes from infection with the Omicron remain uncertain. We evaluate whether clinical outcomes and viral loads differ between Delta and Omicron infections during the period when both variants were co-circulating. METHODS Remnant clinical specimens from patients that tested positive for SARS-CoV-2 after standard of care testing between the last week of November and the end of December 2021were used for whole viral genome sequencing. Cycle threshold values (Ct) for viral RNA, the presence of infectious virus, and levels of respiratory IgG were measured, and clinical outcomes were obtained. Differences in each measure were compared between variants stratified by vaccination status. RESULTS The Omicron variant displaced the Delta during the study period and constituted 95% of the circulating lineages by the end of December 2021. Patients with Omicron infections (N= 1121) were more likely to be vaccinated compared to patients with Delta (N = 910), but were less likely to be admitted, require ICU level care, or succumb to infection regardless of vaccination status. There was no significant difference in Ct values based on the lineage regardless of the vaccination status. Recovery of infectious virus in cell culture was reduced in boosted patients compared to fully vaccinated without a booster and unvaccinated when infected with the Delta lineage. However, in patients with Omicron infections, recovery of infectious virus was not affected by vaccination. CONCLUSIONS Omicron infections of vaccinated individuals are expected, yet admissions are less frequent. Admitted patients might develop severe disease comparable to Delta. Efforts for reducing the Omicron transmission are required as even though the admission risk is lower, the numbers of infections continue to be high. RESEARCH IN CONTEXT EVIDENCE BEFORE THIS STUDY The unprecedented increase in COVID-19 cases in the month of December 2021, associated with the displacement of the Delta variant with the Omicron, triggered a lot of concerns. An understanding of the disease severity associated with infections with Omicron is essential as well as the virological determinants that contributed to its widespread predominance. We searched PubMed for articles published up to January 23, 2022, using the search terms ("Omicron") AND ("Disease severity") as well as ("Omicron") AND ("Viral load") And/ or ("Cell culture"). Our search yielded 3 main studies that directly assessed the omicron's clinical severity in South Africa, its infectious viral load compared to Delta, and the dynamics of viral RNA shedding. In South Africa, compared to Delta, Omicron infected patients showed a significant reduction in severe disease. In this study, Omicron and non-Omicron variants were characterized based on S gene target failure using the TaqPath COVID-19 PCR (Thermo Fisher Scientific). In the study from Switzerland that assessed the infectious viral load in Omicron versus Delta, the authors analyzed only 18 Omicron samples that were all from vaccinated individuals to show that compared to Delta, Omicron had equivalent infectious viral titers. The third study that assessed the Omicron viral dynamics showed that the peak viral RNA in Omicron infections is lower than Delta. No published studies assessed the clinical discrepancies of Omicron and Delta infected patients from the US, nor comprehensively assessed, by viral load and cell culture studies, the characteristics of both variants stratified by vaccination status. ADDED VALUE OF THIS STUDY To the best of our knowledge, this is the only study to date to compare the clinical characteristics and outcomes after infection with the Omicron variant compared to Delta in the US using variants characterized by whole genome sequencing and a selective time frame when both variant co-circulated. It is also the first study to stratify the analysis based on the vaccination status and to compare fully vaccinated patients who didn't receive a booster vaccination to patients who received a booster vaccination. In addition, we provide a unique viral RNA and infectious virus load analyses to compare Delta and Omicron samples from unvaccinated, fully vaccinated, and patients with booster vaccination. IMPLICATIONS OF ALL THE AVAILABLE EVIDENCE Omicron associated with a significant increase in infections in fully and booster vaccinated individuals but with less admissions and ICU level care. Admitted patients showed similar requirements for supplemental oxygen and ICU level care when compared to Delta admitted patients. Viral loads were similar in samples from Omicron and Delta infected patients regardless of the vaccination status. The recovery of infectious virus on cell culture was reduced in samples from patients infected with Delta who received a booster dose, but this was not the case with Omicron. The recovery of infectious virus was equivalent in Omicron infected unvaccinated, fully vaccinated, and samples from patients who received booster vaccination. FUNDING NIH/NIAID Center of Excellence in Influenza Research and Surveillance contract HHS N2772201400007C, Johns Hopkins University, Maryland department of health, Centers for Disease Control and Prevention contract 75D30121C11061.
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Klein EY, Zhu X, Petersen M, Patel EU, Cosgrove SE, Tobian AAR. Methicillin-Resistant and Methicillin-Sensitive Staphylococcus aureus Hospitalizations: National Inpatient Sample, 2016-2019. Open Forum Infect Dis 2022; 9:ofab585. [PMID: 34988254 PMCID: PMC8715851 DOI: 10.1093/ofid/ofab585] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 11/17/2021] [Indexed: 11/16/2022] Open
Abstract
Data from the National Inpatient Sample demonstrate that methicillin-resistant Staphylococcus aureus (MRSA)–related septicemia hospitalizations increased from 1.67 (95% CI, 1.63–1.72) to 1.94 (95% CI, 1.88–2.00; Ptrend < .001) discharges per 1000 hospitalizations between 2016 and 2019. Regionally, the trends were similar. Rates of MSSA-related septicemia and pneumonia hospitalizations also increased significantly over this time period.
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Affiliation(s)
- Eili Y Klein
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Center for Disease Dynamics, Economics & Policy, Washington DC, USA
| | - Xianming Zhu
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Molly Petersen
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Eshan U Patel
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sara E Cosgrove
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Aaron A R Tobian
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Jones GF, Fabre V, Hinson J, Levin S, Toerper M, Townsend J, Cosgrove SE, Saheed M, Klein EY. Improving antimicrobial prescribing for upper respiratory infections in the emergency department: Implementation of peer comparison with behavioral feedback. Antimicrob Steward Healthc Epidemiol 2021; 1:e70. [PMID: 36168488 PMCID: PMC9495637 DOI: 10.1017/ash.2021.240] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 11/08/2021] [Accepted: 11/09/2021] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To reduce inappropriate antibiotic prescribing for acute respiratory infections (ARIs) by employing peer comparison with behavioral feedback in the emergency department (ED). DESIGN A controlled before-and-after study. SETTING The study was conducted in 5 adult EDs at teaching and community hospitals in a health system. PATIENTS Adults presenting to the ED with a respiratory condition diagnosis code. Hospitalized patients and those with a diagnosis code for a non-respiratory condition for which antibiotics are or may be warranted were excluded. INTERVENTIONS After a baseline period from January 2016 to March 2018, 3 EDs implemented a feedback intervention with peer comparison between April 2018 and December 2019 for attending physicians. Also, 2 EDs in the health system served as controls. Using interrupted time series analysis, the inappropriate ARI prescribing rate was calculated as the proportion of antibiotic-inappropriate ARI encounters with a prescription. Prescribing rates were also evaluated for all ARIs. Attending physicians at intervention sites received biannual e-mails with their inappropriate prescribing rate and had access to a dashboard that was updated daily showing their performance relative to their peers. RESULTS Among 28,544 ARI encounters, the inappropriate prescribing rate remained stable at the control EDs between the 2 periods (23.0% and 23.8%). At the intervention sites, the inappropriate prescribing rate decreased significantly from 22.0% to 15.2%. Between periods, the overall ARI prescribing rate was 38.1% and 40.6% in the control group and 35.9% and 30.6% in the intervention group. CONCLUSIONS Behavioral feedback with peer comparison can be implemented effectively in the ED to reduce inappropriate prescribing for ARIs.
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Affiliation(s)
- George F. Jones
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Eastern Virginia Medical School, Norfolk, Virginia
| | - Valeria Fabre
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jeremiah Hinson
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Scott Levin
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Matthew Toerper
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jennifer Townsend
- Division of Infectious Diseases, Greater Baltimore Medical Center, Towson, Maryland
| | - Sara E. Cosgrove
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mustapha Saheed
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Eili Y. Klein
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Center for Disease Dynamics, Economics & Policy, Washington DC
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Lacy K, Schaefer KA, Scheitrum DP, Klein EY. The economic value of genetically engineered mosquitoes as a Malaria control strategy depends on local transmission rates. Biotechnol J 2021; 17:e2100373. [PMID: 34873849 DOI: 10.1002/biot.202100373] [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: 07/16/2021] [Revised: 12/02/2021] [Accepted: 12/03/2021] [Indexed: 11/05/2022]
Abstract
This paper assesses the economic value of genetically engineered (GE) Anopheles gambiae mosquitoes as a malaria control strategy. We use an epidemiological-economic model of malaria transmission to evaluate this technology for a range of village-level transmission settings. In each setting, we evaluate public health outcomes following introduction of GE mosquitoes relative to a "status quo" baseline scenario. We also assess results both in contrast to-and in combination with-a Mass Drug Administration (MDA) strategy. We find that-in low transmission settings-the present value (PV) public health benefits of GE mosquito release are substantial, both relative to status quo dynamics and MDA. In contrast, in high transmission settings, the release of GE mosquitoes may increase steady-state infection rates. Our results indicate that there are substantial policy complementarities when GE mosquito release is combined with local MDA-the combined control strategy can lead to local eradication.
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Affiliation(s)
- Katherine Lacy
- Department of Economics, University of Nevada, Reno, USA
| | - K Aleks Schaefer
- Department of Agricultural Economics, Oklahoma State University, Stillwater, Oklahoma, USA
| | - Daniel P Scheitrum
- Department of Agricultural and Resource Economics, University of Arizona, Tucson, USA
| | - Eili Y Klein
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, USA.,Center for Disease Dynamics, Economics and Policy, Washington, DC, USA
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Petersen MR, Cosgrove SE, Klein EY, Zhu X, Quinn TC, Patel EU, Grabowski MK, Tobian AAR. Clostridioides difficile Prevalence in the United States: National Inpatient Sample, 2016 to 2018. Open Forum Infect Dis 2021; 8:ofab409. [PMID: 34671694 PMCID: PMC8522265 DOI: 10.1093/ofid/ofab409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 07/27/2021] [Indexed: 02/04/2023] Open
Abstract
Data from the National Inpatient Sample indicate that Clostridioides
difficile prevalence decreased from 10.1 (95% confidence interval
[CI] = 9.9–10.3) to 8.6 (95% CI = 8.5–8.8) per 1000 hospital
discharges between 2016 and 2018, after accounting for age, sex, and race. There
was heterogeneity in the prevalence and decrease in prevalence by geographic
region in the United States.
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Affiliation(s)
- Molly R Petersen
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sara E Cosgrove
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Eili Y Klein
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Xianming Zhu
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Thomas C Quinn
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Laboratory of Immunoregulation, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Eshan U Patel
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - M Kate Grabowski
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Aaron A R Tobian
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Amoah J, Klein EY, Chiotos K, Cosgrove SE, Tamma PD. Administration of a β-lactam Prior to Vancomycin as the First Dose of Antibiotic Therapy Improves Survival in Patients with Bloodstream Infections. Clin Infect Dis 2021; 75:98-104. [PMID: 34606585 DOI: 10.1093/cid/ciab865] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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: 07/19/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Prompt initiation of antibiotic therapy improves the survival of patients with bloodstream infections (BSI). We sought to determine if the sequence of administration of the first dose of antibiotic therapy (i.e., β-lactam or vancomycin, if both cannot be administered simultaneously) impacts early mortality for patients with BSI. METHODS We conducted a multicenter, observational study of patients ≥13 years with BSIs to evaluate the association of the sequence of antibiotic administration with 7-day mortality using inverse probability of treatment weighting (IPTW) incorporating propensity scores. Propensity scores were generated based on: demographics, Pitt bacteremia score, ICU status, highest lactate, highest WBC count, Charlson Comorbidity index, severe immunocompromise, administration of active empiric therapy, combination therapy, and time from emergency department arrival to first antibiotic dose. RESULTS Of 3,376 eligible patients, 2,685 (79.5%) received a β-lactam and 691 (20.5%) received vancomycin as their initial antibiotic. In the IPTW cohort, exposed and unexposed patients were similar on all baseline variables. Administration of a β-lactam agent prior to vancomycin protected against 7-day mortality (aOR 0.48 (95% CI: 0.33-0.69)]. Similar results were observed when evaluating 48-hour mortality (aOR 0.45 [95% CI: 0.24-0.83]). Administration of vancomycin prior to a β-lactam was not associated with improved survival in the subgroup of 524 patients with methicillin-resistant Staphylococcus aureus BSI (aOR 0.93 [95% CI: 0.33-2.63]). CONCLUSIONS For ill-appearing patients likely to be experiencing a BSI, prioritizing administration of a β-lactam over vancomycin may reduce early mortality, underscoring the significant impact of a relatively simple practice change on improving patient survival.
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Affiliation(s)
- Joe Amoah
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Eili Y Klein
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kathleen Chiotos
- Department of Anesthesia and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sara E Cosgrove
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Pranita D Tamma
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Ryu S, Hwang Y, Ali ST, Kim DS, Klein EY, Lau EHY, Cowling BJ. Decreased Use of Broad-Spectrum Antibiotics During the Coronavirus Disease 2019 Epidemic in South Korea. J Infect Dis 2021; 224:949-955. [PMID: 33856455 PMCID: PMC8083342 DOI: 10.1093/infdis/jiab208] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [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: 01/03/2021] [Accepted: 04/13/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Early in the coronavirus disease 2019 (COVID-19) pandemic, there was a concern over possible increase in antibiotic use due to coinfections among COVID-19 patients in the community. Here, we evaluate the changes in nationwide use of broad-spectrum antibiotics during the COVID-19 epidemic in South Korea. METHODS We obtained national reimbursement data on the prescription of antibiotics, including penicillin with β-lactamase inhibitors, cephalosporins, fluoroquinolones, and macrolides. We examined the number of antibiotic prescriptions compared with the previous 3 years in the same period from August to July. To quantify the impact of the COVID-19 epidemic on antibiotic use, we developed a regression model adjusting for changes of viral acute respiratory tract infections (ARTIs), which are an important factor driving antibiotic use. RESULTS During the COVID-19 epidemic in South Korea, the broad-spectrum antibiotic use dropped by 15%-55% compared to the previous 3 years. Overall reduction in antibiotic use adjusting for ARTIs was estimated to be 14%-30%, with a larger impact in children. CONCLUSIONS Our study found that broad-spectrum antibiotic use was substantially reduced during the COVID-19 epidemic in South Korea. This reduction can be in part due to reduced ARTIs as a result of stringent public health interventions including social distancing measures.
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Affiliation(s)
- Sukhyun Ryu
- Department of Preventive Medicine, Konyang University College of Medicine, Daejeon, Republic of Korea
| | - Youngsik Hwang
- Department of Preventive Medicine, Konyang University College of Medicine, Daejeon, Republic of Korea
| | - Sheikh Taslim Ali
- World Health Organization Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong Special Administrative Region, China
- Laboratory of Data Discovery for Health, Hong Kong Science and Technology Park, Hong Kong Special Administrative Region, China
| | - Dong-Sook Kim
- Pharmaceutical and Medical Technology Research Team, Department of Research, Health Insurance Review and Assessment Service, Wonju, South Korea
| | - Eili Y Klein
- Center for Disease Dynamics, Economics and Policy, Washington, District of Columbia, USA
- Johns Hopkins University, Baltimore, Maryland, USA
| | - Eric H Y Lau
- World Health Organization Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong Special Administrative Region, China
- Laboratory of Data Discovery for Health, Hong Kong Science and Technology Park, Hong Kong Special Administrative Region, China
| | - Benjamin J Cowling
- World Health Organization Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong Special Administrative Region, China
- Laboratory of Data Discovery for Health, Hong Kong Science and Technology Park, Hong Kong Special Administrative Region, China
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Scully EP, Schumock G, Fu M, Massaccesi G, Muschelli J, Betz J, Klein EY, West NE, Robinson M, Garibaldi BT, Bandeen-Roche K, Zeger S, Klein SL, Gupta A. Sex and Gender Differences in Testing, Hospital Admission, Clinical Presentation, and Drivers of Severe Outcomes From COVID-19. Open Forum Infect Dis 2021; 8:ofab448. [PMID: 34584899 PMCID: PMC8465334 DOI: 10.1093/ofid/ofab448] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 08/30/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Males experience increased severity of illness and mortality from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) compared with females, but the mechanisms of male susceptibility are unclear. METHODS We performed a retrospective cohort analysis of SARS-CoV-2 testing and admission data at 5 hospitals in the Maryland/Washington DC area. Using age-stratified logistic regression models, we quantified the impact of male sex on the risk of the composite outcome of severe disease or death (World Health Organization score 5-8) and tested the impact of demographics, comorbidities, health behaviors, and laboratory inflammatory markers on the sex effect. RESULTS Among 213 175 SARS-CoV-2 tests, despite similar positivity rates, males in age strata between 18 and 74 years were more frequently hospitalized. For the 2626 hospitalized individuals, clinical inflammatory markers (interleukin-6, C-reactive protein, ferritin, absolute lymphocyte count, and neutrophil:lymphocyte ratio) were more favorable for females than males (P < .001). Among 18-49-year-olds, male sex carried a higher risk of severe outcomes, both early (odds ratio [OR], 3.01; 95% CI, 1.75 to 5.18) and at peak illness during hospitalization (OR, 2.58; 95% CI, 1.78 to 3.74). Despite multiple differences in demographics, presentation features, comorbidities, and health behaviors, these variables did not change the association of male sex with severe disease. Only clinical inflammatory marker values modified the sex effect, reducing the OR for severe outcomes in males aged 18-49 years to 1.81 (95% CI, 1.00 to 3.26) early and 1.39 (95% CI, 0.93 to 2.08) at peak illness. CONCLUSIONS Higher inflammatory laboratory test values were associated with increased risk of severe coronavirus disease 2019 for males. A sex-specific inflammatory response to SARS-CoV-2 infection may underlie the sex differences in outcomes.
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Affiliation(s)
- Eileen P Scully
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Grant Schumock
- Department of Biostatistics, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Martina Fu
- Department of Biostatistics, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Guido Massaccesi
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - John Muschelli
- Department of Biostatistics, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Joshua Betz
- Department of Biostatistics, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Eili Y Klein
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Natalie E West
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Matthew Robinson
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Brian T Garibaldi
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Karen Bandeen-Roche
- Department of Biostatistics, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Scott Zeger
- Department of Biostatistics, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sabra L Klein
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Biochemistry and Molecular Biology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Amita Gupta
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Martinez DA, Klein EY, Parent C, Prieto D, Bigelow BF, Saxton RE, Page KR. Latino Household Transmission of SARS-CoV-2. Clin Infect Dis 2021; 74:1675-1677. [PMID: 34463697 PMCID: PMC8499836 DOI: 10.1093/cid/ciab753] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Indexed: 11/18/2022] Open
Abstract
We assessed temporal changes in the household secondary attack rate of SARS-CoV-2 and identified risk factors for transmission in vulnerable Latino households of Baltimore, Maryland. The household SAR was 45.8%, and it appeared to increase as the alpha variant spread, highlighting the magnified risk of spread in unvaccinated populations.
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Affiliation(s)
- Diego A Martinez
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Eili Y Klein
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Cassandra Parent
- Department of Biomedical Engineering, Johns Hopkins University Whiting School of Engineering, Baltimore, MD
| | - Diana Prieto
- School of Industrial Engineering, Pontificia Universidad Católica de Valparaíso, Chile
| | - Benjamin F Bigelow
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ronald E Saxton
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kathleen R Page
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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Muhlebach MS, Jiang X, Kosorok MR, Klein EY, Saiman L. Longitudinal changes and regional variation of incident infection rates at cystic fibrosis centers, United States 2010-2016. J Cyst Fibros 2021; 21:34-39. [PMID: 34456157 DOI: 10.1016/j.jcf.2021.08.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 08/08/2021] [Accepted: 08/16/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Multiple factors affect incident infection rates (IIR) for Pseudomonas aeruginosa (PA) and methicillin resistant Staphylococcus aureus (MRSA) at CF care centers. We assessed changes in IIR across CF centers temporally associated with the 2013 Infection/Prevention & Control guidelines controlling for center-specific factors. METHODS Using the CF Foundation Patient Registry we defined and measured changes in IIR between 2010-2012 and 2014-2016. Data were compared to non-CF rates of MRSA and resistant PA in geographically similar regions. Characteristics of each CF center (n centers: Adult 54 in 2010 to 82 in 2016. Pediatric ∼106) and their respective population were evaluated for associations with IIR and with changes in IIR between the study periods. RESULTS Across the years 35613 patients were included. Incident-infection rates for PA (mean 19.2±0.04% Pediatric, 21.2±0.07% Adult centers) were higher than for MRSA (mean 9.4±0.03% Pediatric, 7.8±0.03% Adult). The IIR decreased for MRSA (-1.54±0.54%, p<0.001) and PA (-4.77±0.63%, p<0.001) at Pediatric but only for PA (-3.20±1.31, p=0.02) at Adult centers. Except for Adult CF, MRSA rates (CF and non-CF) were highest in the South. In 2014-2016, private insurance and a higher proportion of LatinX patients at a center were associated with lower MRSA IIR while larger center size, higher proportion of LatinX, and lower mean center-wide lung function were associated with higher PA IIR. Higher IIR in 2010-2012, were predictive of a more pronounced decrease in IIR in 2014-2016 for MRSA and PA (p<0.001). Different factors indicative of lower social status (smoking, insurance, education) in 2010-2012 predicted decreases in MRSA or PA IIR. CONCLUSION Comparisons of IIR across U.S. CF centers should consider location, ethnic background and socio-economic variables of a center's population.
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Affiliation(s)
- Marianne S Muhlebach
- Department of Pediatrics, Division Pulmonology CB#7217 University of North Carolina, Chapel Hill, NC 27599-7217, United States; Marsico Lung Institute, 130 Mason Farm Rd. CB #7020 UNC-CH Chapel Hill NC 27599-7020. United States.
| | - Xiaotong Jiang
- Department of Biostatistics, University of North Carolina, 170 Rosenau Hall, CB #7400, 135 Dauer Drive, Chapel Hill, NC 27599-7400, United States
| | - Michael R Kosorok
- Department of Biostatistics, University of North Carolina, 170 Rosenau Hall, CB #7400, 135 Dauer Drive, Chapel Hill, NC 27599-7400, United States
| | - Eili Y Klein
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Center for Disease Dynamics, Economics & Policy, Washington, DC
| | - Lisa Saiman
- Department of Pediatrics, Columbia University Irving Medical Center, New York, 622 W 168th St, New York, NY 10032, United States; Department of Infection Prevention & Control, NewYork-Presbyterian Hospital, New York, 622 W 168th St, New York, NY 10032, United States
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Luo CH, Morris CP, Sachithanandham J, Amadi A, Gaston D, Li M, Swanson NJ, Schwartz M, Klein EY, Pekosz A, Mostafa HH. Infection with the SARS-CoV-2 Delta Variant is Associated with Higher Infectious Virus Loads Compared to the Alpha Variant in both Unvaccinated and Vaccinated Individuals. medRxiv 2021:2021.08.15.21262077. [PMID: 34462756 PMCID: PMC8404894 DOI: 10.1101/2021.08.15.21262077] [Citation(s) in RCA: 80] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND The emerging SARS-CoV-2 variant of concern (VOC) B.1.6.17.2 (Delta) quickly displaced the B.1.1.7 (Alpha) and is associated with increases in COVID-19 cases nationally. The Delta variant has been associated with greater transmissibility and higher viral RNA loads in both unvaccinated and fully vaccinated individuals. Data is lacking regarding the infectious virus load in Delta infected individuals and how that compares to individuals infected with other SARS-CoV-2 lineages. METHODS Whole genome sequencing of 2,785 clinical isolates was used to characterize the prevalence of SARS-CoV-2 lineages circulating in the National Capital Region between January and July 2021. Clinical chart reviews were performed for the Delta, Alpha, and B.1.2 (a control predominant lineage prior to both VOCs) variants to evaluate disease severity and outcome and Cycle threshold values (Cts) were compared. The presence of infectious virus was determined using Vero-TMPRSS2 cells and anti-SARS-CoV-2 IgG levels were determined from upper respiratory specimen. An analysis of infection in unvaccinated and fully vaccinated populations was performed. RESULTS The Delta variant displaced the Alpha variant to constitute 88.2% of the circulating lineages in the National Capital Region by July, 2021. The Delta variant associated with increased breakthrough infections in fully vaccinated individuals that were mostly symptomatic when compared to the Alpha breakthrough infections, though it is important to note there was a significantly longer period of time between vaccination and infection with Delta infections. The recovery of infectious virus on cell culture was significantly higher with the Delta variant compared to Alpha in both vaccinated and unvaccinated groups. The impact of vaccination on reducing the recovery of infectious virus from clinical samples was only observed with Alpha variant infections but was strongly associated with low localized SARS-CoV-2 IgG for both variants. A comparison of Ct values showed a significant decrease in the Delta compared to Alpha with no significant differences between unvaccinated and vaccinated groups. CONCLUSIONS Our data indicate that the Delta variant is associated with increased infectious virus loads when compared to the Alpha variant and decreased upper respiratory antiviral IgG levels. Measures to reduce transmission in addition to increasing vaccinations rates have to be implemented to reduce Delta variant spread. FUNDING NIH/NIAID Center of Excellence in Influenza Research and Surveillance contract HHS N2772201400007C, Johns Hopkins University, Maryland department of health, Centers for Disease Control and Prevention contract 75D30121C11061.
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Affiliation(s)
- Chun Huai Luo
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology
| | - C Paul Morris
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology
- National Institute of Allergy and Infectious Disease, National Institutes of Health
| | - Jaiprasath Sachithanandham
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Adannaya Amadi
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology
| | - David Gaston
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology
| | - Maggie Li
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Nicholas J Swanson
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Matthew Schwartz
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology
| | - Eili Y Klein
- Department of Emergency Medicine, Johns Hopkins School of Medicine
- Center for Disease Dynamics, Economics, and Policy, Washington DC
| | - Andrew Pekosz
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Emergency Medicine, Johns Hopkins School of Medicine
| | - Heba H Mostafa
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology
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Jones G, Amoah J, Klein EY, Leeman H, Smith A, Levin S, Milstone AM, Dzintars K, Cosgrove SE, Fabre V. Development of an Electronic Algorithm to Identify in Real Time Adults Hospitalized With Suspected Community-Acquired Pneumonia. Open Forum Infect Dis 2021; 8:ofab291. [PMID: 34189181 PMCID: PMC8231365 DOI: 10.1093/ofid/ofab291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 06/01/2021] [Indexed: 11/12/2022] Open
Abstract
Background Community-acquired pneumonia (CAP) is a major driver of hospital antibiotic use. Efficient methods to identify patients treated for CAP in real time using the electronic health record (EHR) are needed. Automated identification of these patients could facilitate systematic tracking, intervention, and feedback on CAP-specific metrics such as appropriate antibiotic choice and duration. Methods Using retrospective data, we identified suspected CAP cases by searching for patients who received CAP antibiotics AND had an admitting International Classification of Diseases, Tenth Revision (ICD-10) code for pneumonia OR chest imaging within 24 hours OR bacterial urinary antigen testing within 48 hours of admission (denominator query). We subsequently explored different structured and natural language processing (NLP)–derived data from the EHR to identify CAP cases. We evaluated combinations of these electronic variables through receiver operating characteristic (ROC) curves to assess which best identified CAP cases compared to cases identified by manual chart review. Exclusion criteria were age <18 years, absolute neutrophil count <500 cells/mm3, and admission to an oncology unit. Results Compared to the gold standard of chart review, the area under the ROC curve to detect CAP was 0.63 (95% confidence interval [CI], .55–.72; P < .01) using structured data (ie, laboratory and vital signs) and 0.83 (95% CI, .77–.90; P < .01) when NLP-derived data from radiographic reports were included. The sensitivity and specificity of the latter model were 80% and 81%, respectively. Conclusions Creating an electronic tool that effectively identifies CAP cases in real time is possible, but its accuracy is dependent on NLP-derived radiographic data.
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Affiliation(s)
- George Jones
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joe Amoah
- Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Eili Y Klein
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Hannah Leeman
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Aria Smith
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Scott Levin
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Aaron M Milstone
- Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kathryn Dzintars
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Sara E Cosgrove
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Valeria Fabre
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Rao A, Nagourney EM, Chen VH, Hill S, Klein EY, Whalen M, Quinn TC, Hansoti B. Assessing attitudes to ED-based HIV testing: Development of a short-structured survey instrument. PLoS One 2021; 16:e0252372. [PMID: 34043713 PMCID: PMC8158958 DOI: 10.1371/journal.pone.0252372] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 05/15/2021] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Emergency Department (ED)-based HIV counseling and testing (HCT) has had a significant impact on improving rates of HIV diagnosis and linkage to care. Unfortunately, expansion of this strategy to low- and middle-income countries has been limited. Successful implementation of ED-based HCT is dependent on patient and provider acceptance of the intervention, and their attitudes and pre-existing biases towards the disease. This study sought to develop validated survey instruments to assess attitudes towards ED-based HCT. METHODS This cross-sectional study surveyed patients and providers in three EDs in the Eastern Cape province, South Africa. A convenience sample of patients and providers in the ED were surveyed. Exploratory factor analysis was conducted using questions on attitudes to HIV testing to develop validated survey instruments. An ANOVA test assessed variance in attitudes towards HCT based on demographic variables collected. RESULTS A total of 104 patient and 132 provider surveys were completed. Exploratory factor analysis resulted in a 17- and 7-question attitudes survey for patients and providers, respectively. Overall, 92.3% of patients and 70.7% of providers supported ED-based HCT, however, both groups displayed only mildly positive attitudes. Questions representing 'confidentiality' and 'stigma around HIV testing' had the least positive influence on patients' overall attitudes. Questions representing 'comfort with HIV testing' had the least positive influence on providers' overall attitudes. CONCLUSION Our study demonstrated ED patients and providers are generally supportive of ED-based HCT. A validated survey instrument was able to provide a standardized approach to identify barriers to HCT implementation in an ED setting, across contexts. For successful implementation, behavioral interventions must focus on strengthening patient beliefs around confidentiality and the consent process, and providers' comfort levels with providing HIV testing services in the ED.
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Affiliation(s)
- Aditi Rao
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Emily M. Nagourney
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Victoria H. Chen
- Krieger School of Arts and Sciences, Johns Hopkins University, Baltimore, MD, United States of America
| | - Sarah Hill
- Krieger School of Arts and Sciences, Johns Hopkins University, Baltimore, MD, United States of America
| | - Eili Y. Klein
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Madeleine Whalen
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Thomas C. Quinn
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
- Division of Intramural Research, National Institutes of Allergy and Infectious Diseases, NIH, Bethesda, MD, United States of America
| | - Bhakti Hansoti
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
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Cosgrove SE, Klein EY. Reassessing the Link Between Healthcare Access and Outpatient Antibiotic Prescribing. J Infect Dis 2021; 223:2017-2019. [PMID: 33893485 DOI: 10.1093/infdis/jiab221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/21/2021] [Indexed: 11/12/2022] Open
Affiliation(s)
- Sara E Cosgrove
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Eili Y Klein
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Center for Disease Dynamics, Economics and Policy, Washington, District of Colombia, USA
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Scully EP, Schumock G, Fu M, Massaccesi G, Muschelli J, Betz J, Klein EY, West NE, Robinson M, Garibaldi BT, Bandeen-Roche K, Zeger S, Klein SL, Gupta A. Sex and gender differences in COVID testing, hospital admission, presentation, and drivers of severe outcomes in the DC/Maryland region. medRxiv 2021. [PMID: 33851190 DOI: 10.1101/2021.04.05.21253827] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Rates of severe illness and mortality from SARS-CoV-2 are greater for males, but the mechanisms for this difference are unclear. Understanding the differences in outcomes between males and females across the age spectrum will guide both public health and biomedical interventions. Methods Retrospective cohort analysis of SARS-CoV-2 testing and admission data in a health system. Patient-level data were assessed with descriptive statistics and logistic regression modeling was used to identify features associated with increased male risk of severe outcomes. Results In 213,175 SARS-CoV-2 tests, despite similar positivity rates (8.2%F vs 8.9%M), males were more frequently hospitalized (28%F vs 33%M). Of 2,626 hospitalized individuals, females had less severe presenting respiratory parameters and males had more fever. Comorbidity burden was similar, but with differences in specific conditions. Medications relevant for SARS-CoV-2 were used at similar frequency except tocilizumab (M>F). Males had higher inflammatory lab values. In a logistic regression model, male sex was associated with a higher risk of severe outcomes at 24 hours (odds ratio (OR) 3.01, 95%CI 1.75, 5.18) and at peak status (OR 2.58, 95%CI 1.78,3.74) among 18-49 year-olds. Block-wise addition of potential explanatory variables demonstrated that only the inflammatory labs substantially modified the OR associated with male sex across all ages. Conclusion Higher levels of clinical inflammatory labs are the only features that are associated with the heightened risk of severe outcomes and death for males in COVID-19. Trial registration NA. Funding Hopkins inHealth; COVID-19 Administrative Supplement (HHS Region 3 Treatment Center), Office of the ASPR; NIH/NCI U54CA260492 (SK), NIH/NIA U54AG062333 (SK).
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Schueller E, Nandi A, Joshi J, Laxminarayan R, Klein EY. Associations between private vaccine and antimicrobial consumption across Indian states, 2009-2017. Ann N Y Acad Sci 2021; 1494:31-43. [PMID: 33547650 PMCID: PMC8248118 DOI: 10.1111/nyas.14571] [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: 06/18/2020] [Revised: 01/19/2021] [Accepted: 01/21/2021] [Indexed: 12/29/2022]
Abstract
Vaccines can reduce antibiotic use and, consequently, antimicrobial resistance by averting vaccine-preventable and secondary infections. We estimated the associations between private vaccine and antibiotic consumption across Indian states during 2009-2017 using monthly and annual consumption data from IQVIA and employed fixed-effects regression and the Arellano-Bond Generalized Method of Moments (GMM) model for panel data regression, which controlled for income and public sector vaccine use indicators obtained from other sources. In the annual data fixed-effects model, a 1% increase in private vaccine consumption per 1000 under-5 children was associated with a 0.22% increase in antibiotic consumption per 1000 people (P < 0.001). In the annual data GMM model, a 1% increase in private vaccine consumption per 1000 under-5 children was associated with a 0.2% increase in private antibiotic consumption (P < 0.001). In the monthly data GMM model, private vaccine consumption was negatively associated with antibiotic consumption when 32, 34, 35, and 44-47 months had elapsed after vaccine consumption, with a positive association with lags of fewer than 18 months. These results indicate vaccine-induced longer-term reductions in antibiotic use in India, similar to findings of studies from other low- and middle-income countries.
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Affiliation(s)
- Emily Schueller
- Center for Disease Dynamics, Economics & Policy, Silver Spring, Maryland
| | - Arindam Nandi
- Center for Disease Dynamics, Economics & Policy, Silver Spring, Maryland
| | - Jyoti Joshi
- Center for Disease Dynamics, Economics & Policy, New Delhi, India.,Amity Institute of Public Health, Amity University, Noida, Uttar Pradesh, India
| | - Ramanan Laxminarayan
- Center for Disease Dynamics, Economics & Policy, New Delhi, India.,Princeton Environmental Institute, Princeton University, Princeton, New Jersey
| | - Eili Y Klein
- Center for Disease Dynamics, Economics & Policy, Silver Spring, Maryland.,Department of Emergency Medicine, Johns Hopkins School of Medicine, and Department of Epidemiology, Johns Hopkins Bloomberg School of Epidemiology, Baltimore, Maryland
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Same RG, Hsu AJ, Cosgrove SE, Klein EY, Amoah J, Hersh AL, Kronman MP, Tamma PD. Antibiotic-Associated Adverse Events in Hospitalized Children. J Pediatric Infect Dis Soc 2021; 10:622-628. [PMID: 33452808 PMCID: PMC8162628 DOI: 10.1093/jpids/piaa173] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 12/23/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Antibiotic-associated adverse events (AEs) in hospitalized children have not been comprehensively characterized. METHODS We conducted a retrospective observational study of children hospitalized at The Johns Hopkins Hospital receiving ≥24 hours of systemic antibiotics. Consensus regarding antibiotic-associated AE definitions was established by 5 infectious diseases specialists prior to data collection. Two physicians reviewed potential AEs and determined whether they were more likely than not related to antibiotics after comprehensive manual chart review. Inpatient and post-discharge AEs were identified using the Epic Care Everywhere network. AEs evaluated from the initiation of antibiotics until 30 days after antibiotic completion included gastrointestinal, hematologic, hepatobiliary, renal, neurologic, dermatologic, cardiac, myositis, vascular access device-related events, and systemic reactions. Ninety-day AEs included Clostridioides difficile infections, multidrug-resistant organism infections, and clinically significant candidal infections. The impact of AEs was categorized as necessitating additional diagnostic testing, changes in medications, unplanned medical encounters, prolonged or new hospitalizations, or death. RESULTS Among 400 antibiotic courses, 21% were complicated by at least one AE and 30% occurred post-discharge. Each additional day of antibiotics was associated with a 7% increased odds of an AE. Of courses complicated by an AE, 66% required further intervention. Hematologic, gastrointestinal, and renal AEs were the most common, accounting for 31%, 15%, and 11% of AEs, respectively. AEs complicated 35%, 35%, 19%, and 18% of courses of piperacillin-tazobactam, tobramycin, ceftazidime, and vancomycin, respectively. CONCLUSIONS More than 1 in 5 courses of antibiotics administered to hospitalized children are complicated by AEs. Clinicians should weigh the risk of harm against expected benefit when prescribing antibiotics.
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Affiliation(s)
- Rebecca G Same
- Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA,Corresponding Author: Rebecca G. Same, MD, Department of Pediatrics, Washington University School of Medicine in St. Louis, Campus Box 8116, One Children’s Place, St. Louis, MO 63110, USA. E-mail:
| | - Alice J Hsu
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Sara E Cosgrove
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Eili Y Klein
- Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joe Amoah
- Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Adam L Hersh
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Matthew P Kronman
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Pranita D Tamma
- Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Ehmann MR, Klein EY, Kelen GD, Regan L. Emergency Medicine Career Outcomes and Scholarly Pursuits: The Impact of Transitioning From a Three-year to a Four-year Niche-based Residency Curriculum. AEM Educ Train 2021; 5:43-51. [PMID: 33521490 PMCID: PMC7821060 DOI: 10.1002/aet2.10435] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 12/30/2019] [Accepted: 01/07/2020] [Indexed: 05/07/2023]
Abstract
OBJECTIVES In 2008, our emergency medicine (EM) residency program transitioned from a 3-year to a 4-year format. We analyzed the effect that this change had on the scholarly productivity and career choice of graduates, hypothesizing that it would lead residents to be more scholarly productive and graduates to more frequently obtain academic appointments and leadership roles in their first postresidency positions. METHODS This was a retrospective analysis of graduates (N = 95) from a single residency program that underwent a curriculum change from a 3-year to a 4-year format. Three cohorts prior to (n = 36) and five cohorts after (n = 59) this transition were included. The primary outcome of interest was the setting of graduates' first postresidency position. Secondary outcomes included completion of scholarly activity during training and attaining a leadership role in the first postresidency position. RESULTS Of the 4-year program graduates, 44% obtained an academic position compared to 28% of 3-year program graduates. After confounders were controlled for, this difference was statistically discernible only if fellowships were excluded (including fellowship, odds ratio [OR] = 2.25, 95% CI = 0.87 to 5.78; excluding fellowship, OR = 3.53, 95% CI = 1.13 to 11.05). Four-year graduates were more likely to obtain a leadership position immediately after graduation (OR = 13.72, 95% CI = 2.45 to 76.99). Compared to residents in the 3-year program, residents in the 4-year format had a similar likelihood of producing any scholarly work by graduation (OR = 1.69, 95% CI = 0.49 to 5.80) but were more likely to publish peer-reviewed manuscripts (OR = 3.92, 95% CI = 2.25 to 6.83). CONCLUSIONS Compared to 3-year residency graduates, graduates of our 4-year curriculum were more likely to obtain nonfellowship academic appointments and leadership positions immediately after graduation and to publish their scholarly work during residency. This study suggests that residency applicants seeking to be academically productive during residency and leaders in the field of EM should consider training in a 4-year program with similar goals.
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Affiliation(s)
- Michael R. Ehmann
- Department of Emergency MedicineThe Johns Hopkins University School of MedicineBaltimoreMD
| | - Eili Y. Klein
- Department of Emergency MedicineThe Johns Hopkins University School of MedicineBaltimoreMD
- Center for Disease Dynamics, Economics and PolicyWashingtonDC
| | - Gabor D. Kelen
- Department of Emergency MedicineThe Johns Hopkins University School of MedicineBaltimoreMD
| | - Linda Regan
- Department of Emergency MedicineThe Johns Hopkins University School of MedicineBaltimoreMD
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Schar D, Klein EY, Laxminarayan R, Gilbert M, Van Boeckel TP. Global trends in antimicrobial use in aquaculture. Sci Rep 2020; 10:21878. [PMID: 33318576 PMCID: PMC7736322 DOI: 10.1038/s41598-020-78849-3] [Citation(s) in RCA: 131] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 11/25/2020] [Indexed: 01/21/2023] Open
Abstract
Globally aquaculture contributes 8% of animal protein intake to the human diet, and per capita consumption is increasing faster than meat and dairy consumption. Reports have documented antimicrobial use in the rapidly expanding aquaculture industry, which may contribute to the rise of antimicrobial resistance, carrying potential consequences for animal-, human-, and ecosystem-health. However, quantitative antimicrobial use across a highly diversified aquaculture industry is not well characterized. Here, we estimate global trends in antimicrobial use in aquaculture in 2017 and 2030 to help target future surveillance efforts and antimicrobial stewardship policies. We estimate antimicrobial use intensity (mg kg−1) for six species groups though a systematic review of point prevalence surveys, which identified 146 species-specific antimicrobial use rates. We project antimicrobial use in each country by combining mean antimicrobial use coefficients per species group with OECD/FAO Agricultural Outlook and FAO FishStat production volumes. We estimate global antimicrobial consumption in 2017 at 10,259 tons (95% uncertainty interval [UI] 3163–44,727 tons), increasing 33% to 13,600 tons in 2030 (UI 4193–59,295). The Asia–Pacific region represents the largest share (93.8%) of global consumption, with China alone contributing 57.9% of global consumption in 2017. Antimicrobial consumption intensity per species group was: catfish, 157 mg kg−1 (UI 9–2751); trout, 103 mg kg−1 (UI 5–1951); tilapia, 59 mg kg−1 (UI 21–169); shrimp, 46 mg kg−1 (UI 10–224); salmon, 27 mg kg−1 (UI 17–41) and a pooled species group, 208 mg kg−1, (UI 70–622). All antimicrobial classes identified in the review are classified as medically important. We estimate aggregate global human, terrestrial and aquatic food animal antimicrobial use in 2030 at 236,757 tons (95% UI 145,525–421,426), of which aquaculture constitutes 5.7% but carries the highest use intensity per kilogram of biomass (164.8 mg kg−1). This analysis calls for a substantial scale-up of surveillance capacities to monitor global trends in antimicrobial use. Current evidence, while subject to considerable uncertainties, suggests that for some species groups antimicrobial use intensity surpasses consumption levels in terrestrial animals and humans. Acknowledging the fast-growing nature of aquaculture as an important source of animal nutrition globally, our findings highlight the urgent need for enhanced antimicrobial stewardship in a high-growth industry with broad links to water and ecosystem health.
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Affiliation(s)
- Daniel Schar
- Spatial Epidemiology Laboratory, Université Libre de Bruxelles, 1050, Brussels, Belgium.
| | - Eili Y Klein
- Center for Disease Dynamics, Economics & Policy, Washington, DC, 20005, USA
| | - Ramanan Laxminarayan
- Center for Disease Dynamics, Economics & Policy, Washington, DC, 20005, USA.,Princeton Environmental Institute, Princeton University, Princeton, NJ, 08544, USA
| | - Marius Gilbert
- Spatial Epidemiology Laboratory, Université Libre de Bruxelles, 1050, Brussels, Belgium.,Fonds National de la Recherche Scientifique, 1000, Brussels, Belgium
| | - Thomas P Van Boeckel
- Center for Disease Dynamics, Economics & Policy, Washington, DC, 20005, USA.,Institute for Environmental Decisions, ETH Zurich, 8006, Zurich, Switzerland
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Cichowitz C, Loevinsohn G, Klein EY, Colantuoni E, Galiatsatos P, Rennert J, Irvin NA. Racial and ethnic disparities in hospital observation in Maryland. Am J Emerg Med 2020; 46:532-538. [PMID: 33243537 DOI: 10.1016/j.ajem.2020.11.010] [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: 06/05/2020] [Revised: 10/27/2020] [Accepted: 11/04/2020] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVES Hospital observation is a key disposition option from the emergency department (ED) and encompasses up to one third of patients requiring post-ED care. Observation has been associated with higher incidence of catastrophic financial costs and has downstream effects on post-discharge clinical services. Yet little is known about the non-clinical determinants of observation assignment. We sought to evaluate the impact of patient-level demographic factors on observation designation among Maryland patients. METHODS We conducted a retrospective analysis of all ED encounters in Maryland between July 2012 and January 2017 for four priority diagnoses (heart failure, chronic obstructive pulmonary disease [COPD], pneumonia, and acute chest pain) using multilevel logistic models allowing for heterogeneity of the effects across hospitals. The primary exposure was self-reported race and ethnicity. The primary outcome was the initial status assignment from the ED: hospital observation versus inpatient admission. RESULTS Across 46 Maryland hospitals, 259,788 patient encounters resulted in a disposition of inpatient admission (65%) or observation designation (35%). Black (adjusted odds ratio [aOR]: 1.19; 95% confidence interval [CI]: 1.16-1.23) and Hispanic (aOR: 1.11; 95% CI: 1.01-1.21) patients were significantly more likely to be placed in observation than white, non-Hispanic patients. These differences were consistent across the majority of acute-care hospitals in Maryland (27/46). CONCLUSION Black and Hispanic patients in Maryland are more likely to be treated under the observation designation than white, non-Hispanic patients independent of clinical presentation. Race agnostic, time-based status assignments may be key in eliminating these disparities.
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Affiliation(s)
- Cody Cichowitz
- Massachussetts General Hospital, Department of Medicine, Center for Global Health, Boston, MA, USA; Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gideon Loevinsohn
- Johns Hopkins University School of Medicine, Baltimore, MD, USA; Johns Hopkins University Bloomberg School of Public Health, Department of Epidemiology, Baltimore, MD, USA
| | - Eili Y Klein
- Johns Hopkins University School of Medicine, Department of Emergency Medicine, Baltimore, MD, USA; Center for Disease Dynamics, Economics & Policy, Washington, DC, USA
| | - Elizabeth Colantuoni
- Johns Hopkins University Bloomberg School of Public Health, Department of Biostatistics, Baltimore, MD, USA
| | - Panagis Galiatsatos
- Johns Hopkins University School of Medicine, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Baltimore, MD, USA
| | - Jodi Rennert
- Johns Hopkins University School of Medicine, Department of Medicine, Baltimore, MD, USA
| | - Nathan A Irvin
- Johns Hopkins University School of Medicine, Department of Emergency Medicine, Baltimore, MD, USA.
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Martinez DA, Levin SR, Klein EY, Parikh CR, Menez S, Taylor RA, Hinson JS. Early Prediction of Acute Kidney Injury in the Emergency Department With Machine-Learning Methods Applied to Electronic Health Record Data. Ann Emerg Med 2020; 76:501-514. [DOI: 10.1016/j.annemergmed.2020.05.026] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 05/13/2020] [Accepted: 05/18/2020] [Indexed: 12/14/2022]
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