1
|
Coffey KC, Claeys K, Morgan DJ. Diagnostic Stewardship for Urine Cultures. Infect Dis Clin North Am 2024; 38:255-266. [PMID: 38575490 DOI: 10.1016/j.idc.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Urinary tract infections are among the most common infectious diagnoses in health care, but most urinary tract infections are diagnosed inappropriately in patients without signs or symptoms of infection. Asymptomatic bacteriuria leads to inappropriate antibiotic prescribing and negative downstream effects, including antimicrobial resistance, health care-associated infections, and adverse drug events. Diagnostic stewardship is the process of modifying the ordering, performing, or reporting of test results to improve clinical care. Diagnostic stewardship impacts the diagnostic pathway to decrease inappropriate detection and treatment of asymptomatic bacteriuria. This article reviews diagnostic stewardship methods and closes with a case study illustrating these principles in practice.
Collapse
Affiliation(s)
- K C Coffey
- Epidemiology and Public Health, University of Maryland School of Medicine, 10 S. Pine Street, Baltimore, MD 21201, USA.
| | - Kimberley Claeys
- Department of Practice and Science and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Daniel J Morgan
- Epidemiology and Public Health, University of Maryland School of Medicine, 10 S. Pine Street, Baltimore, MD 21201, USA
| |
Collapse
|
2
|
Diekema DJ, Nori P, Stevens MP, Smith MW, Coffey KC, Morgan DJ. Are Contact Precautions "Essential" for the Prevention of Healthcare-associated Methicillin-Resistant Staphylococcus aureus? Clin Infect Dis 2024; 78:1289-1294. [PMID: 37738565 DOI: 10.1093/cid/ciad571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 09/01/2023] [Accepted: 09/19/2023] [Indexed: 09/24/2023] Open
Abstract
The recently updated Society for Healthcare Epidemiology of America, the Infectious Diseases Society of America, and the Association of Professionals in Infection Control practice recommendations for methicillin-resistant Staphylococcus aureus (MRSA) prevention in acute care facilities list contact precautions (CPs) for patients known to be infected or colonized with MRSA as an "essential practice," meaning that it should be adopted in all acute care facilities. We argue that existing evidence on benefits and harms associated with CP do not justify this recommendation. There are no controlled trials that support broad use of CP for MRSA prevention. Data from hospitals that have discontinued CP for MRSA have found no impact on MRSA acquisition or infection. The burden and harms of CP remain concerning, including the environmental impact of increased gown and glove use. We suggest that CP be included among other "additional approaches" to MRSA prevention that can be implemented under specific circumstances (eg outbreaks, evidence of ongoing transmission despite application of essential practices).
Collapse
Affiliation(s)
- Daniel J Diekema
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Department of Medicine, Maine Medical Center, Portland, Maine, USA
| | - Priya Nori
- Department of Medicine, Division of Infectious Diseases, Montefiore Health System, Albert Einstein College of Medicine, Bronx, NewYork, USA
| | - Michael P Stevens
- Department of Medicine, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - Matthew W Smith
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City Veterans Affairs Healthcare System, Iowa City, Iowa, USA
| | - K C Coffey
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Daniel J Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
3
|
Saif NT, Dooley C, Baghdadi JD, Morgan DJ, Coffey KC. Clinical decision support for gastrointestinal panel testing. Antimicrob Steward Healthc Epidemiol 2024; 4:e22. [PMID: 38415090 PMCID: PMC10897720 DOI: 10.1017/ash.2024.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/02/2024] [Accepted: 01/04/2024] [Indexed: 02/29/2024]
Abstract
Objective This study aimed to assess the impact of clinical decision support (CDS) to improve ordering of multiplex gastrointestinal polymerase chain reaction (PCR) testing panel ("GI panel"). Design Single-center, retrospective, before-after study. Setting Tertiary care Veteran's Affairs (VA) Medical Center provides inpatient, outpatient, and residential care. Patients All patients tested with a GI panel between June 22, 2022 and April 20, 2023. Intervention We designed a CDS questionnaire in the electronic medical record (EMR) to guide appropriate ordering of the GI panel. A "soft stop" reminder at the point of ordering prompted providers to confirm five appropriateness criteria: 1) documented diarrhea, 2) no recent receipt of laxatives, 3) C. difficile is not the leading suspected cause of diarrhea, 4) time period since a prior test is >14 days or prior positive test is >4 weeks and 5) duration of hospitalization <72 hours. The CDS was implemented in November 2022. Results Compared to the pre-implementation period (n = 136), fewer tests were performed post-implementation (n = 92) with an IRR of 0.61 (p = 0.003). Inappropriate ordering based on laxative use or undocumented diarrhea decreased (IRR 0.37, p = 0.012 and IRR 0.25, p = 0.08, respectively). However, overall inappropriate ordering and outcome measures did not significantly differ before and after the intervention. Conclusions Implementation of CDS in the EMR decreased testing and inappropriate ordering based on use of laxatives or undocumented diarrhea. However, inappropriate ordering of tests overall remained high post-intervention, signaling the need for continued diagnostic stewardship efforts.
Collapse
Affiliation(s)
- Nadia T. Saif
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Cara Dooley
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jonathan D. Baghdadi
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Daniel J. Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Medicine, Veteran’s Affairs (VA) Maryland Healthcare System, Baltimore, MD, USA
| | - KC Coffey
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Medicine, Veteran’s Affairs (VA) Maryland Healthcare System, Baltimore, MD, USA
| |
Collapse
|
4
|
Coffey KC, Lydecker AD, Roghmann MC. What did nursing home residents think about COVID-19 prevention practices in the era of vaccination and treatment? Am J Infect Control 2023; 51:1452-1454. [PMID: 37295672 PMCID: PMC10247293 DOI: 10.1016/j.ajic.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/01/2023] [Accepted: 06/03/2023] [Indexed: 06/12/2023]
Abstract
We surveyed 57 nursing home residents to assess the subjective impact of COVID-19 prevention practices. Residents were mostly accepting of testing and symptom screening; however, many would like more choices. Sixty-nine percent want to have some say in when or where to mask. Most (87%) residents want to return to group activities. Residents on long-stay units (58%) are more likely than residents on short-stay units (27%) to accept additional risk of COVID-19 transmission to increase their quality of life.
Collapse
Affiliation(s)
- K C Coffey
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD; VA Maryland Health Care System, Baltimore, MD
| | - Alison D Lydecker
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD; VA Maryland Health Care System, Baltimore, MD
| | - Mary-Claire Roghmann
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD; VA Maryland Health Care System, Baltimore, MD.
| |
Collapse
|
5
|
Coffey KC, Morgan DJ, Claeys KC. Diagnostic stewardship: what impacts antibiotics use? Curr Opin Infect Dis 2023; 36:270-275. [PMID: 37431556 DOI: 10.1097/qco.0000000000000927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2023]
Abstract
PURPOSE OF REVIEW The aim of this study was to review recently published diagnostic stewardship studies of common clinical infectious syndromes and the impact on antibiotic prescribing. RECENT FINDINGS Diagnostic stewardship can be implemented within healthcare systems and tailored to infectious syndromes, including urinary tract, gastrointestinal, respiratory and bloodstream infections. In urinary syndromes, diagnostic stewardship can decrease unnecessary urine culturing and associated antibiotic prescribing. Diagnostic stewardship of Clostridium difficile testing can decrease antibiotics and test ordering with a reduction in healthcare-associated C. difficile infections. Respiratory syndrome multiplex arrays can decrease time to results and increase detection of clinically relevant pathogens but may not decrease antibiotics use, or worse, could increase over-prescribing if diagnostic stewardship of ordering practices is not exercised. Lastly, blood culturing practices can be improved by clinical decision support to safely decrease collection and broad-spectrum antibiotic use. SUMMARY Diagnostic stewardship decreases unnecessary antibiotic use in a way that is different from and complementary to antibiotic stewardship. Further studies are needed to quantify the full impact on antibiotic use and resistance. Future considerations should be to institutionalize diagnostic stewardship in patient care activities to leverage integration into systems-based interventions.
Collapse
Affiliation(s)
- K C Coffey
- Department of Epidemiology and Public Health, University of Maryland School of Medicine
| | - Daniel J Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine
| | - Kimberly C Claeys
- Department of Practice and Science and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| |
Collapse
|
6
|
Baghdadi JD, Coffey KC, Belcher R, Frisbie J, Hassan N, Sim D, Malik RD. #Coronavirus on TikTok: user engagement with misinformation as a potential threat to public health behavior. JAMIA Open 2023; 6:ooad013. [PMID: 36844368 PMCID: PMC9949581 DOI: 10.1093/jamiaopen/ooad013] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 01/04/2023] [Accepted: 02/17/2023] [Indexed: 02/22/2023] Open
Abstract
Coronavirus disease (COVID)-related misinformation is prevalent online, including on social media. The purpose of this study was to explore factors associated with user engagement with COVID-related misinformation on the social media platform, TikTok. A sample of TikTok videos associated with the hashtag #coronavirus was downloaded on September 20, 2020. Misinformation was evaluated on a scale (low, medium, and high) using a codebook developed by experts in infectious diseases. Multivariable modeling was used to evaluate factors associated with number of views and presence of user comments indicating intention to change behavior. One hundred and sixty-six TikTok videos were identified and reviewed. Moderate misinformation was present in 36 (22%) videos viewed a median of 6.8 million times (interquartile range [IQR] 3.6-16 million), and high-level misinformation was present in 11 (7%) videos viewed a median of 9.4 million times (IQR 5.1-18 million). After controlling for characteristics and content, videos containing moderate misinformation were less likely to generate a user response indicating intended behavior change. By contrast, videos containing high-level misinformation were less likely to be viewed but demonstrated a nonsignificant trend towards higher engagement among viewers. COVID-related misinformation is less frequently viewed on TikTok but more likely to engage viewers. Public health authorities can combat misinformation on social media by posting informative content of their own.
Collapse
Affiliation(s)
- Jonathan D Baghdadi
- Corresponding Author: Jonathan D. Baghdadi, MD, PhD, Department of Epidemiology and Public Health, University of Maryland School of Medicine, MSTF Suite 334, 10 S Pine Street, Baltimore, MD 21201, USA;
| | - K C Coffey
- Division of Genomic Epidemiology and Clinical Outcomes, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Rachael Belcher
- Division of Urology, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - James Frisbie
- Division of Urology, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Naeemul Hassan
- College of Information Studies, University of Maryland, College Park, Maryland, USA
- Philip Merrill College of Journalism, University of Maryland, College Park, Maryland, USA
| | - Danielle Sim
- Division of Urology, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Rena D Malik
- Division of Urology, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
7
|
Li C, Claeys KC, Morgan DJ, Coffey KC, Tadesse Y. 175. Evaluation of Optimal Urinalysis Criteria for Conditional Urine Culturing. Open Forum Infect Dis 2022. [PMCID: PMC9752347 DOI: 10.1093/ofid/ofac492.253] [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 Asymptomatic bacteriuria is a common condition that is often treated unnecessarily with antimicrobials. Conditional urine reflex culturing leverages the negative predictive value of the absence of pyuria, often defined by a minimum urine white blood cell (WBC) count cutoff > 10 cells/hpf. This value has not been extensively validated. This study evaluated parameters from urinalysis (UA), including various WBC cutoffs, and their ability to detect urinary tract infections (UTIs). Methods Retrospective cohort study of adult patients with or without urinary catheters with at least one UA between July 2020 to July 2021. Conditional reflex urine culturing with urine WBC cutoff of > 10 cells/hpf was standard practice. Pregnant patients, patients with urologic procedures, and those who were mechanically ventilated at time of UA were excluded. UTIs were defined as definitive, probable, possible, or unlikely (Table 1). Comparisons between definitions and those with definitive/probable versus possible/unlikely UTIs were made using Chi-squared test.
UTI definitions ![]() Results 368 patients were included in the final analysis. 154 (41.8%) were male and mean age was 56.9 ± 17.9 years. 117 (31.8%) had urinary catheters. 296 (80.4%) of UAs were treated with antibiotics which were administered after UA collection 89.2% of the time. The total incidence of definitive, probable, possible, and unlikely UTIs according to WBC count is listed in Table 2. UA parameters including leukocyte esterase positivity and presence of nitrites did not differ when compared between definitive/probable versus possible/unlikely UTIs (94.3% vs. 97.1% and 23.9% vs 26.4% respectively). Differences in leukocyte esterase positivity and presence of nitrites were not seen for non-catheterized patients when compared between definitive/probable versus possible/unlikely UTIs (92.3% vs. 96.5% and 21.2% and 29.3% respectively).
Urine WBC categorization stratified by UTI definition ![]() Conclusion Urine WBC cutoff > 10 cells/hpf identifies many patients with unlikely UTIs. Current UA parameters do not definitively differentiate UTIs from not in catheterized or non-catheterized patients. Most patients with a positive UA were treated. Disclosures Kimberly C. Claeys, PharmD, BioFire Diagnostics: Honoraria.
Collapse
Affiliation(s)
- Cecilia Li
- University of Maryland School of Pharmacy, Baltimore, Maryland
| | | | - Daniel J Morgan
- University of Maryland School of Medicine, Baltimore, Maryland
| | - K C Coffey
- University of Maryland School of Medicine, Baltimore, Maryland
| | | |
Collapse
|
8
|
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.
Collapse
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
| |
Collapse
|
9
|
Claeys KC, Trautner BW, Leekha S, Coffey KC, Crnich CJ, Diekema D, Fakih MG, Goetz MB, Gupta K, Jones MM, Leykum L, Liang SY, Pineles L, Pleiss A, Spivak ES, Suda KJ, Taylor J, Rhee C, Morgan DJ. Optimal Urine Culture Diagnostic Stewardship Practice- Results from an Expert Modified-Delphi Procedure. Clin Infect Dis 2021; 75:382-389. [PMID: 34849637 DOI: 10.1093/cid/ciab987] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Urine cultures are nonspecific for infection and often lead to misdiagnosis of urinary tract infection and unnecessary antibiotics. Diagnostic stewardship is a set of procedures that modifies test ordering, processing, and reporting in order to optimize diagnosis and downstream treatment. This study aimed to develop expert guidance on best practices for urine culture diagnostic stewardship. METHODS A RAND-modified Delphi approach with a multidisciplinary expert panel was used to ascertain diagnostic stewardship best practices. Clinical questions to guide recommendations were grouped in three thematic areas (ordering, processing, reporting) in practice settings of emergency department, inpatient, ambulatory, and long-term care. Fifteen experts ranked recommendations on a 9-point Likert scale. Recommendations on which the panel did not reach agreement were discussed in a virtual meeting, and a then second round of ranking by email was completed. After secondary review of results and panel discussion, a series of guidance statements was developed. RESULTS 165 questions were reviewed with the panel reaching agreement on 104, leading to 18 overarching guidance statements. The following strategies were recommended to optimize ordering urine cultures: requiring documentation of symptoms, alerts to discourage ordering in the absence of symptoms, and cancelling repeat cultures. For urine culture processing, conditional reflex urine cultures and urine white blood cell as criteria were supported. For urine culture reporting, appropriate practices included nudges to discourage treatment under specific conditions and selective reporting of antibiotics to guide therapy decisions. CONCLUSIONS These 18 guidance statements can optimize use of the imperfect urine culture for better patient outcomes.
Collapse
Affiliation(s)
- Kimberly C Claeys
- Infectious Diseases, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Barbara W Trautner
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX.,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Surbhi Leekha
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, University of Maryland Medical Center, Baltimore, MD, USA
| | - K C Coffey
- Associate Hospital Epidemiologist, VA Maryland Healthcare System, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Christopher J Crnich
- Chief of Medicine, Hospital Epidemiologist, William S. Middleton Memorial Veterans Hospital, Madison, WI, USA
| | - Dan Diekema
- Division of Infectious Diseases, University of Iowa Carver College of Medicine, University of Iowa Health Care, Iowa City, IA, USA
| | - Mohamad G Fakih
- Chief Quality Officer, Quality Department, Clinical & Network Services, Ascension Healthcare, Grosse Pointe Woods and Wayne State University School of Medicine, Detroit, MI, USA
| | - Matthew Bidwell Goetz
- Infectious Diseases Section, VA Greater Los Angeles Healthcare System, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Kalpana Gupta
- Associate Chief of Staff and Chief, Section of Infectious Diseases, VA Boston Healthcare System, of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Makoto M Jones
- Salt Lake City Veterans Affairs Healthcare System, Internal Medicine - Associate Professor, Division of Epidemiology, The University of Utah, Salt Lake City, UT, USA
| | - Luci Leykum
- Department of Internal Medicine, University of Texas at Austin Dell School of Medicine, Austin, TX, USA
| | - Stephen Y Liang
- Medicine, Division of Infectious Diseases, John T. Milliken Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Lisa Pineles
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ashley Pleiss
- Lead Clinical Nurse, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Emily S Spivak
- Co-Director of the Antimicrobial Stewardship, University of Utah Health and the Salt Lake City Veterans Affairs Healthcare System, Salt Lake City, UT, USA
| | - Katie J Suda
- VA Pittsburgh Healthcare System, Professor of Medicine, Division of General Internal Medicine, University of Pittsburgh and the, Pittsburgh, PA, USA
| | | | - Chanu Rhee
- Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Associate Hospital Epidemiologist, Brigham and Women's Hospital, Boston, MA, USA
| | - Daniel J Morgan
- Chief Hospital, VA Maryland Healthcare System, Epidemiologist Department of Epidemiology, University of Maryland School of Medicine, Baltimore, MD, USA
| |
Collapse
|
10
|
Affiliation(s)
- K C Coffey
- VA Maryland Healthcare System and University of Maryland School of Medicine, Baltimore
| | - Daniel J Diekema
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Daniel J Morgan
- VA Maryland Healthcare System and University of Maryland School of Medicine, Baltimore
| |
Collapse
|
11
|
Coffey KC, Malani P, Morgan DJ. Preventing Transmission of SARS-CoV-2 During College Football Games. JAMA Netw Open 2021; 4:e2135592. [PMID: 34714348 DOI: 10.1001/jamanetworkopen.2021.35592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- K C Coffey
- VA Maryland Healthcare System, Epidemiology and Public Health and Medicine, University of Maryland School of Medicine, Baltimore
| | - Preeti Malani
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Daniel J Morgan
- VA Maryland Healthcare System, Epidemiology and Public Health and Medicine, University of Maryland School of Medicine, Baltimore
| |
Collapse
|
12
|
Affiliation(s)
- Daniel J Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
- VA Maryland Healthcare System, Baltimore
| | - K C Coffey
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
- VA Maryland Healthcare System, Baltimore
| |
Collapse
|
13
|
Kim JJ, Coffey KC, Morgan DJ, Roghmann MC. Nursing home visitation restrictions during COVID-19-Balancing compassion and safety. Am J Infect Control 2021; 49:407. [PMID: 33640112 PMCID: PMC7904469 DOI: 10.1016/j.ajic.2020.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 12/28/2020] [Indexed: 10/24/2022]
Affiliation(s)
| | - K C Coffey
- VA Maryland Health Care System, Baltimore, MD; Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - Daniel J Morgan
- VA Maryland Health Care System, Baltimore, MD; Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - Mary-Claire Roghmann
- VA Maryland Health Care System, Baltimore, MD; Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| |
Collapse
|
14
|
Turbett SE, Anahtar MN, Pattanayak V, Azar MM, Coffey KC, Eng G, Rudolf JW, Lewandrowski KB, Baron J, Rosenberg ES, Branda JA. Use of Routine Complete Blood Count Results to Rule Out Anaplasmosis Without the Need for Specific Diagnostic Testing. Clin Infect Dis 2021; 70:1215-1221. [PMID: 31044232 DOI: 10.1093/cid/ciz346] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 04/25/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Anaplasmosis presents with fever, headache, and laboratory abnormalities including leukopenia and thrombocytopenia. Polymerase chain reaction (PCR) is the preferred diagnostic but is overutilized. We determined if routine laboratory tests could exclude anaplasmosis, improving PCR utilization. METHODS Anaplasma PCR results from a 3-year period, with associated complete blood count (CBC) and liver function test results, were retrospectively reviewed. PCR rejection criteria, based on white blood cell (WBC) and platelet (PLT) counts, were developed and prospectively applied in a mock stewardship program. If rejection criteria were met, a committee mock-refused PCR unless the patient was clinically unstable or immunocompromised. RESULTS WBC and PLT counts were the most actionable routine tests for excluding anaplasmosis. Retrospective review demonstrated that rejection criteria of WBC ≥11 000 cells/µL or PLT ≥300 000 cells/µL would have led to PCR refusal in 428 of 1685 true-negative cases (25%) and 3 of 66 true-positive cases (5%) involving clinically unstable or immunocompromised patients. In the prospective phase, 155 of 663 PCR requests (23%) met rejection criteria and were reviewed by committee, which endorsed refusal in 110 of 155 cases (71%) and approval in 45 (29%), based on clinical criteria. PCR was negative in all 45 committee-approved cases. Only 1 of 110 mock-refused requests yielded a positive PCR result; this patient was already receiving doxycycline at the time of testing. CONCLUSIONS A CBC-based stewardship algorithm would reduce unnecessary Anaplasma PCR testing, without missing active cases. Although the prospectively evaluated screening approach involved medical record review, this was unnecessary to prevent errors and could be replaced by a rejection comment specifying clinical situations that might warrant overriding the algorithm.
Collapse
Affiliation(s)
- Sarah E Turbett
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston.,Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Melis N Anahtar
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Vikram Pattanayak
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Marwan M Azar
- Department of Section of Infectious Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - K C Coffey
- Department of Section of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - George Eng
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Joseph W Rudolf
- Department of Laboratory Medicine and Pathology, University of Minnesota Medical School, Minneapolis
| | - Kent B Lewandrowski
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Jason Baron
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Eric S Rosenberg
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston
| | - John A Branda
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston
| |
Collapse
|
15
|
Kim JJ, Coffey KC, Morgan DJ, Roghmann MC. Lessons learned - Outbreaks of COVID-19 in nursing homes. Am J Infect Control 2020; 48:1279-1280. [PMID: 32739235 PMCID: PMC7392952 DOI: 10.1016/j.ajic.2020.07.028] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 07/23/2020] [Indexed: 12/17/2022]
Affiliation(s)
| | - K C Coffey
- VA Maryland Health Care System, Baltimore, MD; Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - Daniel J Morgan
- VA Maryland Health Care System, Baltimore, MD; Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - Mary-Claire Roghmann
- VA Maryland Health Care System, Baltimore, MD; Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| |
Collapse
|
16
|
Affiliation(s)
- Rachel P Simmons
- From the Department of Medicine, Boston Medical Center (R.P.S.), the Department of Medicine, Boston University School of Medicine (R.P.S.), the Departments of Medicine (D.M.D., R.M.H.), Radiology (J.-A.O.S.), and Pathology (K.C.C.), Massachusetts General Hospital, and the Departments of Medicine (D.M.D., R.M.H.), Radiology (J.-A.O.S.), and Pathology (K.C.C.), Harvard Medical School - all in Boston
| | - David M Dudzinski
- From the Department of Medicine, Boston Medical Center (R.P.S.), the Department of Medicine, Boston University School of Medicine (R.P.S.), the Departments of Medicine (D.M.D., R.M.H.), Radiology (J.-A.O.S.), and Pathology (K.C.C.), Massachusetts General Hospital, and the Departments of Medicine (D.M.D., R.M.H.), Radiology (J.-A.O.S.), and Pathology (K.C.C.), Harvard Medical School - all in Boston
| | - Jo-Anne O Shepard
- From the Department of Medicine, Boston Medical Center (R.P.S.), the Department of Medicine, Boston University School of Medicine (R.P.S.), the Departments of Medicine (D.M.D., R.M.H.), Radiology (J.-A.O.S.), and Pathology (K.C.C.), Massachusetts General Hospital, and the Departments of Medicine (D.M.D., R.M.H.), Radiology (J.-A.O.S.), and Pathology (K.C.C.), Harvard Medical School - all in Boston
| | - Rocio M Hurtado
- From the Department of Medicine, Boston Medical Center (R.P.S.), the Department of Medicine, Boston University School of Medicine (R.P.S.), the Departments of Medicine (D.M.D., R.M.H.), Radiology (J.-A.O.S.), and Pathology (K.C.C.), Massachusetts General Hospital, and the Departments of Medicine (D.M.D., R.M.H.), Radiology (J.-A.O.S.), and Pathology (K.C.C.), Harvard Medical School - all in Boston
| | - K C Coffey
- From the Department of Medicine, Boston Medical Center (R.P.S.), the Department of Medicine, Boston University School of Medicine (R.P.S.), the Departments of Medicine (D.M.D., R.M.H.), Radiology (J.-A.O.S.), and Pathology (K.C.C.), Massachusetts General Hospital, and the Departments of Medicine (D.M.D., R.M.H.), Radiology (J.-A.O.S.), and Pathology (K.C.C.), Harvard Medical School - all in Boston
| |
Collapse
|
17
|
Affiliation(s)
- Molly L Paras
- From the Departments of Medicine (M.L.P., E.P.H.) and Pathology (R.K.F., K.C.C.), Massachusetts General Hospital, and the Departments of Medicine (M.L.P., E.P.H.) and Pathology (R.K.F., K.C.C.), Harvard Medical School - both in Boston
| | - Emily P Hyle
- From the Departments of Medicine (M.L.P., E.P.H.) and Pathology (R.K.F., K.C.C.), Massachusetts General Hospital, and the Departments of Medicine (M.L.P., E.P.H.) and Pathology (R.K.F., K.C.C.), Harvard Medical School - both in Boston
| | - Ruth K Foreman
- From the Departments of Medicine (M.L.P., E.P.H.) and Pathology (R.K.F., K.C.C.), Massachusetts General Hospital, and the Departments of Medicine (M.L.P., E.P.H.) and Pathology (R.K.F., K.C.C.), Harvard Medical School - both in Boston
| | - K C Coffey
- From the Departments of Medicine (M.L.P., E.P.H.) and Pathology (R.K.F., K.C.C.), Massachusetts General Hospital, and the Departments of Medicine (M.L.P., E.P.H.) and Pathology (R.K.F., K.C.C.), Harvard Medical School - both in Boston
| |
Collapse
|