Comparative antimicrobial use in coronavirus disease 2019 (COVID-19) and non-COVID-19 inpatients from 2019 to 2020: A multicenter ecological study

OBJECTIVE

We sought to determine whether increased antimicrobial use (AU) at the onset of the coronavirus disease 2019 (COVID-19) pandemic was driven by greater AU in COVID-19 patients only, or whether AU also increased in non-COVID-19 patients.

DESIGN

In this retrospective observational ecological study from 2019 to 2020, we stratified inpatients by COVID-19 status and determined relative percentage differences in median monthly AU in COVID-19 patients versus non-COVID-19 patients during the COVID-19 period (March-December 2020) and the pre-COVID-19 period (March-December 2019). We also determined relative percentage differences in median monthly AU in non-COVID-19 patients during the COVID-19 period versus the pre-COVID-19 period. Statistical significance was assessed using Wilcoxon signed-rank tests.

SETTING

The study was conducted in 3 acute-care hospitals in Chicago, Illinois.

PATIENTS

Hospitalized patients.

RESULTS

Facility-wide AU for broad-spectrum antibacterial agents predominantly used for hospital-onset infections was significantly greater in COVID-19 patients versus non-COVID-19 patients during the COVID-19 period (with relative increases of 73%, 66%, and 91% for hospitals A, B, and C, respectively), and during the pre-COVID-19 period (with relative increases of 52%, 64%, and 66% for hospitals A, B, and C, respectively). In contrast, facility-wide AU for all antibacterial agents was significantly lower in non-COVID-19 patients during the COVID-19 period versus the pre-COVID-19 period (with relative decreases of 8%, 7%, and 8% in hospitals A, B, and C, respectively).

CONCLUSIONS

AU for broad-spectrum antimicrobials was greater in COVID-19 patients compared to non-COVID-19 patients at the onset of the pandemic. AU for all antibacterial agents in non-COVID-19 patients decreased in the COVID-19 period compared to the pre-COVID-19 period.

Evolving availability and standardization of patient attributes for matching

Variation in availability, format, and standardization of patient attributes across health care organizations impacts patient-matching performance. We report on the changing nature of patient-matching features available from 2010-2020 across diverse care settings. We asked 38 health care provider organizations about their current patient attribute data-collection practices. All sites collected name, date of birth (DOB), address, and phone number. Name, DOB, current address, social security number (SSN), sex, and phone number were most commonly used for cross-provider patient matching. Electronic health record queries for a subset of 20 participating sites revealed that DOB, first name, last name, city, and postal codes were highly available (>90%) across health care organizations and time. SSN declined slightly in the last years of the study period. Birth sex, gender identity, language, country full name, country abbreviation, health insurance number, ethnicity, cell phone number, email address, and weight increased over 50% from 2010 to 2020. Understanding the wide variation in available patient attributes across care settings in the United States can guide selection and standardization efforts for improved patient matching in the United States.

Computing antimicrobial use/antimicrobial resistance ratios: A novel way to assess inpatient antimicrobial utilization using current National Healthcare Safety Network metrics

BACKGROUND

Current methods for benchmarking inpatient antimicrobial use (AU) could benefit from combining AU with antimicrobial resistance (AR) information to provide metrics benchmarked to microbiological data; this may yield more instructive and better risk-adjusted measurements than AU and AR in isolation.

METHODS

In this retrospective single-center study, we computed facility-wide AU/AR ratios from 2019 to 2020 for specific antimicrobial agents and corresponding AR events, and compared median monthly AU/AR ratios between March 2019 through December 2019 (pre-COVID period) and March 2020 through December 2020 (COVID period). Aggregate AU was expressed as a ratio to aggregate AR events for antimicrobials that typically have activity against the AR organism and are frequently used to treat the AR organism in clinical practice. We also computed AU/AR ratios in our surgical intensive care unit in the pre-COVID period.

RESULTS

High-median facility-wide monthly AU/AR ratios were observed for intravenous vancomycin/methicillin-resistant Staphylococcus aureus, with 130.0 in the pre-COVID period and 121.3 in the COVID period (p =.520). Decreases in facility-wide median monthly AU/AR ratios were observed between periods for meropenem/ESBL Enterobacterales (20.9 vs. 7.9, p < .001), linezolid/vancomycin-resistant Enterococcus (48.5 vs. 15.8, p =.004), and daptomycin/vancomycin-resistant Enterococcus (32.2 vs. 4.8, p = .002). Increases in facility-wide median monthly AU/AR ratios were observed between periods for ceftazidime-avibactam/carbapenem-resistant Enterobacterales (0.0 vs. 3.2, p = .020) and ceftazidime-avibactam/multidrug-resistant Pseudomonas aeruginosa (0.0 vs. 4.0, p = .017). The AU/AR ratio for intravenous vancomycin/methicillin-resistant S. aureus in the surgical intensive care unit was 191.5 in the pre-COVID period.

CONCLUSIONS

AU/AR ratios may be used to supplement current AU and AR metrics. Future directions should include the development of more AU metrics benchmarked to microbiological information. AU metrics more specific to transplant infectious diseases should be developed.

Prevalence of Select New Symptoms and Conditions Among Persons Aged Younger Than 20 Years and 20 Years or Older at 31 to 150 Days After Testing Positive or Negative for SARS-CoV-2

IMPORTANCE

New symptoms and conditions can develop following SARS-CoV-2 infection. Whether they occur more frequently among persons with SARS-CoV-2 infection compared with those without is unclear.

OBJECTIVE

To compare the prevalence of new diagnoses of select symptoms and conditions between 31 and 150 days after testing among persons who tested positive vs negative for SARS-CoV-2.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study analyzed aggregated electronic health record data from 40 health care systems, including 338 024 persons younger than 20 years and 1 790 886 persons aged 20 years or older who were tested for SARS-CoV-2 during March to December 2020 and who had medical encounters between 31 and 150 days after testing.

MAIN OUTCOMES AND MEASURES

International Statistical Classification of Diseases, Tenth Revision, Clinical Modification codes were used to capture new symptoms and conditions that were recorded 31 to 150 days after a SARS-CoV-2 test but absent in the 18 months to 7 days prior to testing. The prevalence of new symptoms and conditions was compared between persons with positive and negative SARS-CoV-2 tests stratified by age (20 years or older and young than 20 years) and care setting (nonhospitalized, hospitalized, or hospitalized and ventilated).

RESULTS

A total of 168 701 persons aged 20 years or older and 26 665 younger than 20 years tested positive for SARS-CoV-2, and 1 622 185 persons aged 20 years or older and 311 359 younger than 20 years tested negative. Shortness of breath was more common among persons with a positive vs negative test result among hospitalized patients (≥20 years: prevalence ratio [PR], 1.89 [99% CI, 1.79-2.01]; <20 years: PR, 1.72 [99% CI, 1.17-2.51]). Shortness of breath was also more common among nonhospitalized patients aged 20 years or older with a positive vs negative test result (PR, 1.09 [99% CI, 1.05-1.13]). Among hospitalized persons aged 20 years or older, the prevalence of new fatigue (PR, 1.35 [99% CI, 1.27-1.44]) and type 2 diabetes (PR, 2.03 [99% CI, 1.87-2.19]) was higher among those with a positive vs a negative test result. Among hospitalized persons younger than 20 years, the prevalence of type 2 diabetes (PR, 2.14 [99% CI, 1.13-4.06]) was higher among those with a positive vs a negative test result; however, the prevalence difference was less than 1%.

CONCLUSIONS AND RELEVANCE

In this cohort study, among persons hospitalized after a positive SARS-CoV-2 test result, diagnoses of certain symptoms and conditions were higher than among those with a negative test result. Health care professionals should be aware of symptoms and conditions that may develop after SARS-CoV-2 infection, particularly among those hospitalized after diagnosis.

Stopping Hospital Infections With Environmental Services (SHINE): A Cluster-randomized Trial of Intensive Monitoring Methods for Terminal Room Cleaning on Rates of Multidrug-resistant Organisms in the Intensive Care Unit

BACKGROUND

Multidrug-resistant organisms (MDROs) frequently contaminate hospital environments. We performed a multicenter, cluster-randomized, crossover trial of 2 methods for monitoring of terminal cleaning effectiveness.

METHODS

Six intensive care units (ICUs) at 3 medical centers received both interventions sequentially, in randomized order. Ten surfaces were surveyed each in 5 rooms weekly, after terminal cleaning, with adenosine triphosphate (ATP) monitoring or an ultraviolet fluorescent marker (UV/F). Results were delivered to environmental services staff in real time with failing surfaces recleaned. We measured monthly rates of MDRO infection or colonization, including methicillin-resistant Staphylococcus aureus, Clostridioides difficile, vancomycin-resistant Enterococcus, and MDR gram-negative bacilli (MDR-GNB) during a 12-month baseline period and sequential 6-month intervention periods, separated by a 2-month washout. Primary analysis compared only the randomized intervention periods, whereas secondary analysis included the baseline.

RESULTS

The ATP method was associated with a reduction in incidence rate of MDRO infection or colonization compared with the UV/F period (incidence rate ratio [IRR] 0.876; 95% confidence interval [CI], 0.807-0.951; P = .002). Including the baseline period, the ATP method was associated with reduced infection with MDROs (IRR 0.924; 95% CI, 0.855-0.998; P = .04), and MDR-GNB infection or colonization (IRR 0.856; 95% CI, 0.825-0.887; P < .001). The UV/F intervention was not associated with a statistically significant impact on these outcomes. Room turnaround time increased by a median of 1 minute with the ATP intervention and 4.5 minutes with UV/F compared with baseline.

CONCLUSIONS

Intensive monitoring of ICU terminal room cleaning with an ATP modality is associated with a reduction of MDRO infection and colonization.

Racial and Ethnic Disparities in Receipt of Medications for Treatment of COVID-19 - United States, March 2020-August 2021

The COVID-19 pandemic has magnified longstanding health care and social inequities, resulting in disproportionately high COVID-19-associated illness and death among members of racial and ethnic minority groups (1). Equitable use of effective medications (2) could reduce disparities in these severe outcomes (3). Monoclonal antibody (mAb) therapies against SARS-CoV-2, the virus that causes COVID-19, initially received Emergency Use Authorization (EUA) from the Food and Drug Administration (FDA) in November 2020. mAbs are typically administered in an outpatient setting via intravenous infusion or subcutaneous injection and can prevent progression of COVID-19 if given after a positive SARS-CoV-2 test result or for postexposure prophylaxis in patients at high risk for severe illness.^† Dexamethasone, a commonly used steroid, and remdesivir, an antiviral drug that received EUA from FDA in May 2020, are used in inpatient settings and help prevent COVID-19 progression^§ (2). No large-scale studies have yet examined the use of mAb by race and ethnicity. Using COVID-19 patient electronic health record data from 41 U.S. health care systems that participated in the PCORnet, the National Patient-Centered Clinical Research Network,^¶ this study assessed receipt of medications for COVID-19 treatment by race (White, Black, Asian, and Other races [including American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, and multiple or Other races]) and ethnicity (Hispanic or non-Hispanic). Relative disparities in mAb** treatment among all patients^†† (805,276) with a positive SARS-CoV-2 test result and in dexamethasone and remdesivir treatment among inpatients^§§ (120,204) with a positive SARS-CoV-2 test result were calculated. Among all patients with positive SARS-CoV-2 test results, the overall use of mAb was infrequent, with mean monthly use at 4% or less for all racial and ethnic groups. Hispanic patients received mAb 58% less often than did non-Hispanic patients, and Black, Asian, or Other race patients received mAb 22%, 48%, and 47% less often, respectively, than did White patients during November 2020-August 2021. Among inpatients, disparities were different and of lesser magnitude: Hispanic inpatients received dexamethasone 6% less often than did non-Hispanic inpatients, and Black inpatients received remdesivir 9% more often than did White inpatients. Vaccines and preventive measures are the best defense against infection; use of COVID-19 medications postexposure or postinfection can reduce morbidity and mortality and relieve strain on hospitals but are not a substitute for COVID-19 vaccination. Public health policies and programs centered around the specific needs of communities can promote health equity (4). Equitable receipt of outpatient treatments, such as mAb and antiviral medications, and implementation of prevention practices are essential to reducing existing racial and ethnic inequities in severe COVID-19-associated illness and death.

Computer Informatics for Infection Control

Computer informatics have the potential to improve infection control outcomes in surveillance, prevention, and public health. Surveillance activities include surveillance of infections, device use, and facility/ward outbreak detection and investigation. Prevention activities include awareness of multidrug-resistant organism carriage on admission, identification of high-risk individuals or populations, reducing device use, and antimicrobial stewardship. Enhanced communication with public health and other health care facilities across networks includes automated electronic communicable disease reporting, syndromic surveillance, and regional outbreak detection. Computerized public health networks may represent the next major evolution in infection control. This article reviews the use of informatics for infection control.

Disparities and Temporal Trends in COVID-19 Exposures and Mitigating Behaviors Among Black and Hispanic Adults in an Urban Setting

IMPORTANCE

COVID-19, caused by SARS-CoV-2 virus, has disproportionately affected Black and Hispanic communities in the US, which can be attributed to social factors including inconsistent public health messaging and suboptimal adoption of prevention efforts.

OBJECTIVES

To identify behaviors and evaluate trends in COVID-19-mitigating practices in a predominantly Black and Hispanic population, to identify differences in practices by self-reported ethnicity, and to evaluate whether federal emergency financial assistance was associated with SARS-CoV-2 acquisition.

DESIGN, SETTING, AND PARTICIPANTS

This survey study was conducted by telephone from July 1 through August 30, 2020, on a random sample of adults who underwent SARS-CoV-2 testing at a safety-net health care system in Chicago during the surge in COVID-19 cases in the spring of 2020. Behaviors and receipt of a stimulus check were compared between participants testing positive and negative for SARS-CoV-2. Differences in behaviors and temporal trends were assessed by race and ethnicity.

MAIN OUTCOMES AND MEASURES

SARS-CoV-2 infection was assessed using nasopharyngeal quantitative reverse transcriptase-polymerase chain reaction testing. Mitigating behaviors and federal emergency financial assistance were assessed by survey. Race and ethnicity data were collected from electronic health records.

RESULTS

Of 750 randomly sampled individuals, 314 (41.9%) consented to participate (169 [53.8%] women). Of those, 159 (51%) self-reported as Hispanic and 155 (49%) as non-Hispanic (120 [38.2%] Black), of whom 133 (84%) and 76 (49%) tested positive for SARS-CoV-2, respectively. For all participants, consistent mask use (public transport: adjusted odds ratio [aOR], 0.00; 95% CI, 0.00-0.34; social gatherings: aOR, 0.10; 95% CI, 0.00-0.50; running errands: aOR, 0.18; 95% CI, 0.07-0.42; at work: aOR, 0.23; 95% CI, 0.07-0.79) and hand sanitizer use (aOR, 0.26; 95% CI, 0.13-0.52) were associated with lower odds of infection. During 3 sampled weeks, mitigation practices were less frequent among Hispanic compared with non-Hispanic participants (eg, mask use while running errands: aOR, 0.26; 95% CI, 0.15-0.46). Hispanic participants were at high risk of infection (aOR, 5.52; 95% CI, 4.30-7.08) and more likely to work outside the home (aOR, 2.05; 95% CI, 1.27-3.30) compared with non-Hispanic participants, possibly because of limited receipt of stimulus checks (aOR, 0.03; 95% CI, 0.02-0.07) or unemployment benefits (aOR, 0.36; 95% CI, 0.16-0.74).

CONCLUSIONS AND RELEVANCE

In this survey study of adults in a large US city, public health messaging improved preventive behaviors over time but lagged among Hispanic participants; messaging tailored to Hispanic communities, especially for mask use, should be prioritized. Hispanic individuals were at higher risk for infection, more often worked outside the home, and were less likely to have received a stimulus check; this suggests larger studies are needed to evaluate the provision of economic support on SARS-CoV-2 transmission dynamics in low-income populations.

Spatial, Ecologic, and Clinical Epidemiology of Community-Onset, Ceftriaxone-Resistant Enterobacteriaceae, Cook County, Illinois, USA

We performed a spatial and mixed ecologic study of community-onset Enterobacteriaceae isolates collected from a public healthcare system in Cook County, Illinois, USA. Individual-level data were collected from the electronic medical record and census tract–level data from the US Census Bureau. Associations between individual- and population-level characteristics and presence of ceftriaxone resistance were determined by logistic regression analysis. Spatial analysis confirmed nonrandom distribution of ceftriaxone resistance across census tracts, which was associated with higher percentages of Hispanic, foreign-born, and uninsured residents. Individual-level analysis showed that ceftriaxone resistance was associated with male sex, an age range of 35–85 years, race or ethnicity other than non-Hispanic Black, inpatient encounter, and percentage of foreign-born residents in the census tract of isolate provenance. Our findings suggest that the likelihood of community-onset ceftriaxone resistance in Enterobacteriaceae is influenced by geographic and population-level variables. The development of effective mitigation strategies might depend on better accounting for these factors.

Significant Regional Differences in Antibiotic Use Across 576 US Hospitals and 11 701 326 Adult Admissions, 2016-2017

BACKGROUND

Quantifying the amount and diversity of antibiotic use in United States hospitals assists antibiotic stewardship efforts but is hampered by limited national surveillance. Our study aimed to address this knowledge gap by examining adult antibiotic use across 576 hospitals and nearly 12 million encounters in 2016-2017.

METHODS

We conducted a retrospective study of patients aged ≥ 18 years discharged from hospitals in the Premier Healthcare Database between 1 January 2016 and 31 December 2017. Using daily antibiotic charge data, we mapped antibiotics to mutually exclusive classes and to spectrum of activity categories. We evaluated relationships between facility and case-mix characteristics and antibiotic use in negative binomial regression models.

RESULTS

The study included 11 701 326 admissions, totaling 64 064 632 patient-days, across 576 hospitals. Overall, patients received antibiotics in 65% of hospitalizations, at a crude rate of 870 days of therapy (DOT) per 1000 patient-days. By class, use was highest among β-lactam/β-lactamase inhibitor combinations, third- and fourth-generation cephalosporins, and glycopeptides. Teaching hospitals averaged lower rates of total antibiotic use than nonteaching hospitals (834 vs 957 DOT per 1000 patient-days; P < .001). In adjusted models, teaching hospitals remained associated with lower use of third- and fourth-generation cephalosporins and antipseudomonal agents (adjusted incidence rate ratio [95% confidence interval], 0.92 [.86-.97] and 0.91 [.85-.98], respectively). Significant regional differences in total and class-specific antibiotic use also persisted in adjusted models.

CONCLUSIONS

Adult inpatient antibiotic use remains high, driven predominantly by broad-spectrum agents. Better understanding reasons for interhospital usage differences, including by region and teaching status, may inform efforts to reduce inappropriate antibiotic prescribing.

Regional Spread of blaNDM-1-Containing Klebsiella pneumoniae ST147 in Post-Acute Care Facilities

BACKGROUND

Carbapenem-resistant Enterobacterales (CRE) harboring blaKPC have been endemic in Chicago-area healthcare networks for more than a decade. During 2016-2019, a series of regional point-prevalence surveys identified increasing prevalence of blaNDM-containing CRE in multiple long-term acute care hospitals (LTACHs) and ventilator-capable skilled nursing facilities (vSNFs). We performed a genomic epidemiology investigation of blaNDM-producing CRE to understand their regional emergence and spread.

METHODS

We performed whole-genome sequencing on New Delhi metallo-beta-lactamase (NDM)+ CRE isolates from 4 point-prevalence surveys across 35 facilities (LTACHs, vSNFs, and acute care hospital medical intensive care units) in the Chicago area and investigated the genomic relatedness and transmission dynamics of these isolates over time.

RESULTS

Genomic analyses revealed that the rise of NDM+ CRE was due to the clonal dissemination of an sequence type (ST) 147 Klebsiella pneumoniae strain harboring blaNDM-1 on an IncF plasmid. Dated phylogenetic reconstructions indicated that ST147 was introduced into the region around 2013 and likely acquired NDM around 2015. Analyzing the relatedness of strains within and between facilities supported initial increases in prevalence due to intrafacility transmission in certain vSNFs, with evidence of subsequent interfacility spread among LTACHs and vSNFs connected by patient transfer.

CONCLUSIONS

We identified a regional outbreak of blaNDM-1 ST147 that began in and disseminated across Chicago area post-acute care facilities. Our findings highlight the importance of performing genomic surveillance at post-acute care facilities to identify emerging threats.

Variability in comorbidites and health services use across homeless typologies: multicenter data linkage between healthcare and homeless systems

BACKGROUND

Homelessness is associated with substantial morbidity. Data linkages between homeless and health systems are important to understand unique needs across homeless populations, identify homeless individuals not registered in homeless databases, quantify the impact of housing services on health-system use, and motivate health systems and payers to contribute to housing solutions.

METHODS

We performed a cross-sectional survey including six health systems and two Homeless Management Information Systems (HMIS) in Cook County, Illinois. We performed privacy-preserving record linkage to identify homelessness through HMIS or ICD-10 codes captured in electronic medical records. We measured the prevalence of health conditions and health-services use across the following typologies: housing-service utilizers stratified by service provided (stable, stable plus unstable, unstable) and non-utilizers (i.e., homelessness identified through diagnosis codes-without receipt of housing services).

RESULTS

Among 11,447 homeless recipients of healthcare, nearly 1 in 5 were identified by ICD10 code alone without recorded homeless services (n = 2177; 19%). Almost half received homeless services that did not include stable housing (n = 5444; 48%), followed by stable housing (n = 3017; 26%), then receipt of both stable and unstable services (n = 809; 7%). Setting stable housing recipients as the referent group, we found a stepwise increase in behavioral-health conditions from stable housing to those known as homeless solely by health systems. Compared to those in stable housing, prevalence rate ratios (PRR) for those without homeless services were as follows: depression (PRR = 2.2; 95% CI 1.9 to 2.5), anxiety (PRR = 2.5; 95% CI 2.1 to 3.0), schizophrenia (PRR = 3.3; 95% CI 2.7 to 4.0), and alcohol-use disorder (PRR = 4.4; 95% CI 3.6 to 5.3). Homeless individuals who had not received housing services relied on emergency departments for healthcare-nearly 3 of 4 visited at least one and many (24%) visited multiple.

CONCLUSIONS

Differences in behavioral-health conditions and health-system use across homeless typologies highlight the particularly high burden among homeless who are disconnected from homeless services. Fragmented and high use of emergency departments for care should motivate health systems and payers to promote housing solutions, especially those that incorporate substance use and mental health treatment.

How to Choose Target Facilities in a Region to Implement Carbapenem-resistant Enterobacteriaceae Control Measures

BACKGROUND

When trying to control regional spread of antibiotic-resistant pathogens such as carbapenem-resistant Enterobacteriaceae (CRE), decision makers must choose the highest-yield facilities to target for interventions. The question is, with limited resources, how best to choose these facilities.

METHODS

Using our Regional Healthcare Ecosystem Analyst-generated agent-based model of all Chicago metropolitan area inpatient facilities, we simulated the spread of CRE and different ways of choosing facilities to apply a prevention bundle (screening, chlorhexidine gluconate bathing, hand hygiene, geographic separation, and patient registry) to a resource-limited 1686 inpatient beds.

RESULTS

Randomly selecting facilities did not impact prevalence, but averted 620 new carriers and 175 infections, saving $6.3 million in total costs compared to no intervention. Selecting facilities by type (eg, long-term acute care hospitals) yielded a 16.1% relative prevalence decrease, preventing 1960 cases and 558 infections, saving $62.4 million more than random selection. Choosing the largest facilities was better than random selection, but not better than by type. Selecting by considering connections to other facilities (ie, highest volume of discharge patients) yielded a 9.5% relative prevalence decrease, preventing 1580 cases and 470 infections, and saving $51.6 million more than random selection. Selecting facilities using a combination of these metrics yielded the greatest reduction (19.0% relative prevalence decrease, preventing 1840 cases and 554 infections, saving $59.6 million compared with random selection).

CONCLUSIONS

While choosing target facilities based on single metrics (eg, most inpatient beds, most connections to other facilities) achieved better control than randomly choosing facilities, more effective targeting occurred when considering how these and other factors (eg, patient length of stay, care for higher-risk patients) interacted as a system.

How Long-Term Acute Care Hospitals Can Play an Important Role in Controlling Carbapenem-Resistant Enterobacteriaceae in a Region: A Simulation Modeling Study

Typically, long-term acute care hospitals (LTACHs) have less experience in and incentives to implementing aggressive infection control for drug-resistant organisms such as carbapenem-resistant Enterobacteriaceae (CRE) than acute care hospitals. Decision makers need to understand how implementing control measures in LTACHs can impact CRE spread regionwide. Using our Chicago metropolitan region agent-based model to simulate CRE spread and control, we estimated that a prevention bundle in only LTACHs decreased prevalence by a relative 4.6%-17.1%, averted 1,090-2,795 new carriers, 273-722 infections and 37-87 deaths over 3 years and saved $30.5-$69.1 million, compared with no CRE control measures. When LTACHs and intensive care units intervened, prevalence decreased by a relative 21.2%. Adding LTACHs averted an additional 1,995 carriers, 513 infections, and 62 deaths, and saved $47.6 million beyond implementation in intensive care units alone. Thus, LTACHs may be more important than other acute care settings for controlling CRE, and regional efforts to control drug-resistant organisms should start with LTACHs as a centerpiece.

Epidemiology of COVID-19 vs. influenza: Differential failure of COVID-19 mitigation among Hispanics, Cook County Health, Illinois

Background

During the early phases of the COVID-19 pandemic in the U.S., African-American or Hispanic communities were disproportionately impacted. To better understand the epidemiology and relative effects of COVID-19 among hospitalized Hispanic patients, we compared individual and census-tract level characteristics of patients diagnosed with COVID-19 to those diagnosed with influenza, another viral infection with respiratory transmission. We evaluated temporal changes in epidemiology related to a shelter-in-place mandate.

Methods

We evaluated patients hospitalized at Cook County Health, the safety-net health system for the Chicago metropolitan area. Among self-identified hospitalized Hispanic patients, we compared those with influenza (2019–2020 season) to COVID-19 infection during March 16, 2020-May 11, 2020. We used multivariable analysis to identify differences in individual and census-tract level characteristics between the two groups.

Results

Relative to non-Hispanic blacks and whites, COVID-19 rapidly increased among Hispanics during promotion of social-distancing policies. Whereas non-Hispanic blacks were more likely to be hospitalized for influenza, Hispanic patients predominated among COVID-19 infections (40% relative increase compared to influenza). In the comparative analysis of influenza and COVID-19, Hispanic patients with COVID-19 were more likely to reside in census tracts with higher proportions of residents with the following characteristics: Hispanic; no high school diploma; non-US citizen; limited English speaking ability; employed in manufacturing or construction; and overcrowding. By multivariable analysis, Hispanic patients hospitalized with COVID-19 compared to those with influenza were more likely to be male (adjusted OR = 1.8; 95% CI 1.1 to 2.9), obese (aOR = 2.5; 95% CI 1.5 to 4.2), or reside in a census tract with ≥40% of residents without a high-school diploma (aOR = 2.5; 95% CI 1.3 to 4.8).

Conclusions

The rapid and disproportionate increase in COVID-19 hospitalizations among Hispanics after the shelter-in-place mandate indicates that public health strategies were inadequate in protecting this population—in particular, for those residing in neighborhoods with lower levels of educational attainment.

Electronically Available Patient Claims Data Improve Models for Comparing Antibiotic Use Across Hospitals: Results from 576 U.S. Facilities

Background

The Centers for Disease Control and Prevention (CDC) uses standardized antimicrobial administration ratios (SAARs)—that is, observed-to-predicted ratios—to compare antibiotic use across facilities. CDC models adjust for facility characteristics when predicting antibiotic use but do not include patient diagnoses and comorbidities that may also affect utilization. This study aimed to identify comorbidities causally related to appropriate antibiotic use and to compare models that include these comorbidities and other patient-level claims variables to a facility model for risk-adjusting inpatient antibiotic utilization.

Methods

The study included adults discharged from Premier Database hospitals in 2016–2017. For each admission, we extracted facility, claims, and antibiotic data. We evaluated 7 models to predict an admission’s antibiotic days of therapy (DOTs): a CDC facility model, models that added patient clinical constructs in varying layers of complexity, and an external validation of a published patient-variable model. We calculated hospital-specific SAARs to quantify effects on hospital rankings. Separately, we used Delphi Consensus methodology to identify Elixhauser comorbidities associated with appropriate antibiotic use.

Results

The study included 11 701 326 admissions across 576 hospitals. Compared to a CDC-facility model, a model that added Delphi-selected comorbidities and a bacterial infection indicator was more accurate for all antibiotic outcomes. For total antibiotic use, it was 24% more accurate (respective mean absolute errors: 3.11 vs 2.35 DOTs), resulting in 31–33% more hospitals moving into bottom or top usage quartiles postadjustment.

Conclusions

Adding electronically available patient claims data to facility models consistently improved antibiotic utilization predictions and yielded substantial movement in hospitals’ utilization rankings.

How Introducing a Registry With Automated Alerts for Carbapenem-resistant Enterobacteriaceae (CRE) May Help Control CRE Spread in a Region

BACKGROUND

Regions are considering the use of electronic registries to track patients who carry antibiotic-resistant bacteria, including carbapenem-resistant Enterobacteriaceae (CRE). Implementing such a registry can be challenging and requires time, effort, and resources; therefore, there is a need to better understand the potential impact.

METHODS

We developed an agent-based model of all inpatient healthcare facilities (90 acute care hospitals, 9 long-term acute care hospitals, 351 skilled nursing facilities, and 12 ventilator-capable skilled nursing facilities) in the Chicago metropolitan area, surrounding communities, and patient flow using our Regional Healthcare Ecosystem Analyst software platform. Scenarios explored the impact of a registry that tracked patients carrying CRE to help guide infection prevention and control.

RESULTS

When all Illinois facilities participated (n = 402), the registry reduced the number of new carriers by 11.7% and CRE prevalence by 7.6% over a 3-year period. When 75% of the largest Illinois facilities participated (n = 304), registry use resulted in a 11.6% relative reduction in new carriers (16.9% and 1.2% in participating and nonparticipating facilities, respectively) and 5.0% relative reduction in prevalence. When 50% participated (n = 201), there were 10.7% and 5.6% relative reductions in incident carriers and prevalence, respectively. When 25% participated (n = 101), there was a 9.1% relative reduction in incident carriers (20.4% and 1.6% in participating and nonparticipating facilities, respectively) and 2.8% relative reduction in prevalence.

CONCLUSIONS

Implementing an extensively drug-resistant organism registry reduced CRE spread, even when only 25% of the largest Illinois facilities participated due to patient sharing. Nonparticipating facilities garnered benefits, with reductions in new carriers.

Predicting Carbapenem-Resistant Enterobacteriaceae Carriage at the Time of Admission Using a Statewide Hospital Discharge Database

BACKGROUND

Timely identification of patients likely to harbor carbapenem-resistant Enterobacteriaceae (CRE) can help health care facilities provide effective infection control and treatment. We evaluated whether a model utilizing prior health care information from a state hospital discharge database could predict a patient's probability of CRE colonization at the time of hospital admission.

METHODS

We performed a case-control study using the Illinois hospital discharge database. From a 2014-2015 patient cohort, we defined cases as index adult patient hospital encounters with a positive CRE culture collected within the first 3 days of hospitalization, as reported to the Illinois XDRO registry; controls were all patient admissions from the same hospital and month. We split the data into training (~60%) and validation (~40%) sets and developed a logistic regression model to estimate coefficients for predictors of interest.

RESULTS

We identified 486 index cases and 340 005 controls. Independent risk factors for CRE at the time of admission were age, number of short-term acute care hospital (STACH) hospitalizations in the prior 365 days, mean STACH length of stay, number of long-term acute care hospital (LTACH) hospitalizations in the prior 365 days, mean LTACH length of stay, current admission to LTACH, and prior hospital admission with an infection diagnosis code. When applying the model to the validation data set, the area under the receiver operating characteristic curve was 0.84.

CONCLUSIONS

A prediction model utilizing prior health care exposure information could discriminate patients who were likely to harbor CRE at the time of hospital admission.

Regional Spread of an Outbreak of Carbapenem-Resistant Enterobacteriaceae Through an Ego Network of Healthcare Facilities

Background

In 2013, New Delhi metallo-β-lactamase (NDM)-producing Escherichia coli, a type of carbapenem-resistant Enterobacteriaceae uncommon in the United States, was identified in a tertiary care hospital (hospital A) in northeastern Illinois. The outbreak was traced to a contaminated duodenoscope. Patient-sharing patterns can be described through social network analysis and ego networks, which could be used to identify hospitals most likely to accept patients from a hospital with an outbreak.

Methods

Using Illinois' hospital discharge data and the Illinois extensively drug-resistant organism (XDRO) registry, we constructed an ego network around hospital A. We identified which facilities NDM outbreak patients subsequently visited and whether the facilities reported NDM cases.

Results

Of the 31 outbreak cases entered into the XDRO registry who visited hospital A, 19 (61%) were subsequently admitted to 13 other hospitals during the following 12 months. Of the 13 hospitals, the majority (n = 9; 69%) were in our defined ego network, and 5 of those 9 hospitals consequently reported at least 1 additional NDM case. Ego network facilities were more likely to identify cases compared to a geographically defined group of facilities (9/22 vs 10/66; P = .01); only 1 reported case fell outside of the ego network.

Conclusions

The outbreak hospital's ego network accurately predicted which hospitals the outbreak patients would visit. Many of these hospitals reported additional NDM cases. Prior knowledge of this ego network could have efficiently focused public health resources on these high-risk facilities.

Prescribing Associated with High-Risk Opioid Exposures Among Non-cancer Chronic Users of Opioid Analgesics: a Social Network Analysis

BACKGROUND

The continued rise in fatalities from opioid analgesics despite a steady decline in the number of individual prescriptions directing ≥ 90 morphine milligram equivalents (MME)/day may be explained by patient exposures to redundant prescriptions from multiple prescribers.

OBJECTIVES

We evaluated prescribers' specialty and social network characteristics associated with high-risk opioid exposures resulting from single-prescriber high-daily dose prescriptions or multi-prescriber discoordination.

DESIGN

Retrospective cohort study.

PARTICIPANTS

A cohort of prescribers with opioid analgesic prescription claims for non-cancer chronic opioid users in an Illinois Medicaid managed care program in 2015-2016.

MAIN MEASURES

Per prescriber rates of single-prescriber high-daily-dose prescriptions or multi-prescriber discoordination.

KEY RESULTS

For 2280 beneficiaries, 36,798 opioid prescription claims were submitted by 3532 prescribers. Compared to 3% of prescriptions (involving 6% of prescribers and 7% of beneficiaries) that directed ≥ 90 MME/day, discoordination accounted for a greater share of high-risk exposures-13% of prescriptions (involving 23% of prescribers and 24% of beneficiaries). The following specialties were at highest risk of discoordinated prescribing compared to internal medicine: dental (incident rate ratio (95% confidence interval) 5.9 (4.6, 7.5)), emergency medicine (4.7 (3.8, 5.8)), and surgical subspecialties (4.2 (3.0, 5.8)). Social network analysis identified 2 small interconnected prescriber communities of high-volume pain management specialists, and 3 sparsely connected groups of predominantly low-volume primary care or emergency medicine clinicians. Using multivariate models, we found that the sparsely connected sociometric positions were a risk factor for high-risk exposures.

CONCLUSION

Low-volume prescribers in the social network's periphery were at greater risk of intended or discoordinated prescribing than interconnected high-volume prescribers. Interventions addressing discoordination among low-volume opioid prescribers in non-integrated practices should be a priority. Demands for enhanced functionality and integration of Prescription Drug Monitoring Programs or referrals to specialized multidisciplinary pain management centers are potential policy implications.

Association between cannabis use and complications related to ulcerative colitis in hospitalized patients: A propensity matched retrospective cohort study

Ulcerative colitis (UC) is a chronic inflammatory process that is occasionally associated with complications that cause significant morbidity and mortality. Studies in experimental animal models have demonstrated a beneficial effect of cannabis on intestinal inflammation. It is however unknown if this corresponds to fewer complications for patients with Ulcerative Colitis.We aimed to compare the prevalence of UC related complications and certain key clinical endpoints among cannabis users and nonusers hospitalized with a primary diagnosis of UC, or primary diagnosis of a UC-related complication with a secondary diagnosis of UC.Using data from the Healthcare Cost and Utilization Project-National Inpatient Sample (NIS) during 2010-2014, a total of 298 cannabis users with UC were compared to a propensity score matched group of nonusers with UC. We evaluated several UC-related complications and clinical endpoints.Within our matched cohort, prevalence of partial or total colectomy was lower in cannabis users compared to nonusers (4.4% vs 9.7%, P = .010) and there was a trend toward a lower prevalence of bowel obstruction (6.4% vs 10.7%, P = .057). Cannabis users had shorter hospital length-of-stay (4.5 vs 5.7 days P < .007) compared to their nonuser counterparts.Cannabis use may mitigate some of the well described complications of UC among hospitalized patients. Our findings need further evaluation, ideally through more rigorous clinical trials.

576. Continuing Disparities in Virologic Control for People Living with HIV (PLWH) Receiving Care at a Large, Urban, Safety-Net Clinic

Background

The National HIV/AIDS Strategy highlights reduction of HIV-related disparities as a key goal. Despite universal access to therapy in the United States, the CDC estimates that only 58% of PLWH have achieved virologic suppression. We carried out a recent analysis of virologic suppression, examining for associated factors for PLWH receiving care at one of the nation’s largest, urban, safety-net clinics in order to identify ongoing outcome disparities.

Methods

Ruth M. Rothstein CORE Center, Cook County Health and Hospital System’s large, urban, safety-net HIV clinic cares for nearly 5,000 PLHW in the Chicago area. We report rates of virologic suppression for PLWH who attended at least one primary care visit between March 31, 2017 and April 1, 2018. We assessed for associations between key demographic characteristics, inclusive of zip code of residence, and virologic suppression (VL < 200 copies/mL³).

Results

A total of 4,660 patients attended at least one visit primary care visit at CORE between March 31, 2017 and April 1, 2018, of whom 84% were virologically suppressed. Sixty-six percent of our patients were African-American (AA), and 25% identified as Hispanic; 74% were male; patients’ median age was 49. On multivariate analysis, AA race (OR 1.54, P = 0.006) correlated with ongoing viremia (VL > 200 copies/mL³), while older age (age group 30 – 49, OR 0.62, P < 0.001; age group > 50 OR 0.27, P < 0.001) and identification as Hispanic (OR 0.63, P = 0.011) associated with virologic suppression. Other HIV transmission categories and demographic characteristics, inclusive of a health literacy measure, did not associate with virologic control. Of the Top 10 most populated zip codes of residence for our patients, three had a significantly higher proportion of viremic patients; while one had significantly more suppressed patients.

Conclusion

Disparities in virologic suppression persist in younger and African-American PLWH who attended care at Chicago’s largest, safety-net HIV clinic, with our data highlighting particular geographic areas of need. Structural interventions and quality improvement initiatives, at the health system and regional level, must continue to focus on improving outcomes for PLWH who fall into these demographic categories.

Disclosures

R. Lubelchek, Viiv: Scientific Advisor, Salary.

2167. Predicting Carbapenem-Resistant Enterobacteriaceae (CRE) Carriage on Admission using Updated Statewide Hospital Discharge Data

Background

We previously built a patient-level prediction model to assess an individual’s risk of Carbapenem-resistant Enterobacteriaceae (CRE) carriage upon hospital admission based on the following factors: past hospital visits (short- and long-term acute care (STACHs and LTACHs)), endoscopic procedures, infection-related diagnosis codes, and patient age and sex. Our model discriminated CRE cases relatively well (c-statistic = 0.86). In the hopes of operationalizing our results, we evaluated the distribution of predicted probabilities on an updated dataset using existing model parameters.

Methods

We used Illinois Hospital discharge data (CYs 2015–2016) with ICD-10 diagnosis and procedure codes to establish baseline exposure history (2015) and to generate predicted probabilities (2016). We calculated the number of hospital visits and the average number of hospital days in the past year (STACH and LTACH). We identified infection-related diagnosis codes using prior knowledge, and included procedure codes for endoscopic retrograde cholangiopancreatography (ERCP). We then used the model parameters from our previous work to generate predicted probabilities corresponding to each hospital visit.

Results

Our study year (2016) included 1,229,158 visits by 816,500 unique adult patients. Sixty-two percent of patients had no inpatient visits in the previous year. Among those with a prior hospitalization, the median STACH length of stay was 4 days (IQR: 2–6). Three thousand five hundred and sixty-six patients (0.4%) had previous LTACH exposure upon admission, with a median length of stay of 25 days (IQR: 13–40). Thirty-two percent of hospital visits had an infection-related diagnosis code, and 0.5% had an ERCP procedure code. Of the more than 1.2 million visits, our model predicted 10,614 visits associated with a CRE risk of over 1%, 946 visits of over 10%, and 96 visits by 63 unique patients with over a 50% risk. On average, highest risk patients were exposed to (median) 15 (7–97) STACH, 104 LTACH (37–174) days; 83% had infection codes.

Conclusion

Using a large, de-identified statewide dataset, we were able to identify a small number of extremely high-risk individuals. Selective screening of these individuals upon admission could prove to be a valuable way to identify CRE-colonized patients in order to take proper precautions.

Disclosures

All authors: No reported disclosures.

Electronically Available Comorbidities Should Be Used in Surgical Site Infection Risk Adjustment

Background

Healthcare-associated infections such as surgical site infections (SSIs) are used by the Centers for Medicare and Medicaid Services (CMS) as pay-for-performance metrics. Risk adjustment allows a fairer comparison of SSI rates across hospitals. Until 2016, Centers for Disease Control and Prevention (CDC) risk adjustment models for pay-for-performance SSI did not adjust for patient comorbidities. New 2016 CDC models only adjust for body mass index and diabetes.

Methods

We performed a multicenter retrospective cohort study of patients undergoing surgical procedures at 28 US hospitals. Demographic data and International Classification of Diseases, Ninth Revision codes were obtained on patients undergoing colectomy, hysterectomy, and knee and hip replacement procedures. Complex SSIs were identified by infection preventionists at each hospital using CDC criteria. Model performance was evaluated using measures of discrimination and calibration. Hospitals were ranked by SSI proportion and risk-adjusted standardized infection ratios (SIR) to assess the impact of comorbidity adjustment on public reporting.

Results

Of 45394 patients at 28 hospitals, 573 (1.3%) developed a complex SSI. A model containing procedure type, age, race, smoking, diabetes, liver disease, obesity, renal failure, and malnutrition showed good discrimination (C-statistic, 0.73) and calibration. When comparing hospital rankings by crude proportion to risk-adjusted ranks, 24 of 28 (86%) hospitals changed ranks, 16 (57%) changed by ≥2 ranks, and 4 (14%) changed by >10 ranks.

Conclusions

We developed a well-performing risk adjustment model for SSI using electronically available comorbidities. Comorbidity-based risk adjustment should be strongly considered by the CDC and CMS to adequately compare SSI rates across hospitals.

Regional Epidemiology of Methicillin-Resistant Staphylococcus aureus Among Adult Intensive Care Unit Patients Following State-Mandated Active Surveillance

Background

In 2007, Illinois became the first state in the United States to mandate active surveillance of methicillin-resistant Staphylococcus aureus (MRSA). The Illinois law applies to intensive care unit (ICU) patients; contact precautions are required for patients found to be MRSA colonized. However, the effectiveness of a legislated "search and isolate" approach to reduce MRSA burden among critically ill patients is uncertain. We evaluated whether the prevalence of MRSA colonization declined in the 5 years after the start of mandatory active surveillance.

Methods

All hospitals with an ICU having ≥10 beds in Chicago, Illinois, were eligible to participate in single-day serial point prevalence surveys. We assessed MRSA colonization among adult ICU patients present at time of survey using nasal and inguinal swab cultures. The primary outcome was region-wide MRSA colonization prevalence over time.

Results

All 25 eligible hospitals (51 ICUs) participated in serial point prevalence surveys over 8 survey periods (2008-2013). A total of 3909 adult ICU patients participated in the point prevalence surveys, with 432 (11.1%) found to be colonized with MRSA (95% confidence interval [CI], 10.1%-12.0%). The MRSA colonization prevalence among patients was unchanged during the study period; year-over-year relative risk for MRSA colonization was 0.97 (95% CI, .89-1.05; P = .48).

Conclusions

MRSA colonization prevalence among critically ill adult patients did not decline during the time period following legislatively mandated MRSA active surveillance. Our findings highlight the limits of legislated MRSA active surveillance as a strategy to reduce MRSA colonization burden among ICU patients.

Assessing the Ability of Hospital Diagnosis Codes to Detect Inpatient Exposure to Antibacterial Agents

OBJECTIVE Because antibacterial history is difficult to obtain, especially when the exposure occurred at an outside hospital, we assessed whether infection-related diagnostic billing codes, which are more readily available through hospital discharge databases, could infer prior antibacterial receipt. DESIGN Retrospective cohort study. PARTICIPANTS This study included 121,916 hospitalizations representing 78,094 patients across the 3 hospitals. METHODS We obtained hospital inpatient data from 3 Chicago-area hospitals. Encounters were categorized as "infection" if at least 1 International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) code indicated a bacterial infection. From medication administration records, we categorized antibacterial agents and calculated total therapy days using Centers for Disease Control and Prevention (CDC) definitions. We evaluated bivariate associations between infection encounters and 3 categories of antibacterial exposure: any, broad spectrum, or surgical prophylaxis. We constructed multivariable models to evaluate adjusted risk ratios for antibacterial receipt. RESULTS Of the 121,916 inpatient encounters (78,094 patients) across the 3 hospitals, 24% had an associated infection code, 47% received an antibacterial, and 13% received a broad-spectrum antibacterial. Infection-related ICD-9-CM codes were associated with a 2-fold increase in antibacterial administration compared to those lacking such codes (RR, 2.29; 95% confidence interval [CI], 2.27-2.31) and a 5-fold increased risk for broad-spectrum antibacterial administration (RR, 5.52; 95% CI, 5.37-5.67). Encounters with infection codes had 3 times the number of antibacterial days. CONCLUSIONS Infection diagnostic billing codes are strong surrogate markers for prior antibacterial exposure, especially to broad-spectrum antibacterial agents; such an association can be used to enhance early identification of patients at risk of multidrug-resistant organism (MDRO) carriage at the time of admission. Infect Control Hosp Epidemiol 2018;39:377-382.

A Novel Patient Recruitment Strategy: Patient Selection Directly from the Community through Linkage to Clinical Data

OBJECTIVE

This article presents and describes our methods in developing a novel strategy for recruitment of underrepresented, community-based participants, for pragmatic research studies leveraging routinely collected electronic health record (EHR) data.

METHODS

We designed a new approach for recruiting eligible patients from the community, while also leveraging affiliated health systems to extract clinical data for community participants. The strategy involves methods for data collection, linkage, and tracking. In this workflow, potential participants are identified in the community and surveyed regarding eligibility. These data are then encrypted and deidentified via a hashing algorithm for linkage of the community participant back to a record at a clinical site. The linkage allows for eligibility verification and automated follow-up. Longitudinal data are collected by querying the EHR data and surveying the community participant directly. We discuss this strategy within the context of two national research projects, a clinical trial and an observational cohort study.

CONCLUSION

The community-based recruitment strategy is a novel, low-touch, clinical trial enrollment method to engage a diverse set of participants. Direct outreach to community participants, while utilizing EHR data for clinical information and follow-up, allows for efficient recruitment and follow-up strategies. This new strategy for recruitment links data reported from community participants to clinical data in the EHR and allows for eligibility verification and automated follow-up. The workflow has the potential to improve recruitment efficiency and engage traditionally underrepresented individuals in research.

Patient-level exclusions from mHealth in a safety-net health system

Excitement about mobile health (mHealth) for improving care transitions is fueled by widespread adoption of smartphones across all social segments, but new disparities can emerge around nonadopters of technology-based communications. We conducted a cross-sectional survey of urban low-income adults to assess inadequate reading health literacy and limited English proficiency as factors affecting access to and engagement with mHealth. Although the proportion owning smartphones were comparable to national figures, adjusted analysis showed fewer patients with inadequate reading health literacy having Internet access (odds ratio [95% confidence interval]: 0.50 [0.26-0.95]), e-mail (0.43 [0.24-0.79]), and interest in using e-mail (0.34 [0.18-0.65]) for healthcare communications. Fewer patients with limited English proficiency were interested in using mobile apps (0.2 [0.09-0.46]). Inpatient status was independently associated with less interest in text messaging (0.46 [0.25-0.87]). mHealth exclusions around literacy and language proficiency threaten equity, and innovative solutions are needed to realize mHealth's potential for reducing disparities. Journal of Hospital Medicine 2017;12:90-93.

Importance of Molecular Methods to Determine Whether a Probiotic is the Source of Lactobacillus Bacteremia

There has been an increasing interest in the use of probiotic products for the prevention of Clostridium difficile infection (CDI). Bio-K+(®) is a commercial probiotic product comprising three strains of lactobacilli--Lactobacillus acidophilus CL1285(®), Lact. casei LBC80R(®) and Lact. rhamnosus CLR2(®)--that have been applied to prevent CDI. Generally considered as safe, lactobacilli have potential to cause bacteremia, endocarditis and other infections. The source of Lactobacillus bacteremia can be normal human flora or lactobacilli-containing probiotic. The aim of this study was to assess whether probiotic lactobacilli caused bacteremia and to show the value of molecular identification and typing techniques to determine probiotic and patient strain relatedness. We report an episode of Lactobacillus bacteremia in a 69-year-old man admitted to a hospital with severe congestive heart failure. During his hospitalization, he required long-term antibiotic therapy. Additionally, the patient received Bio-K+(®) probiotic as part of a quality improvement project to prevent CDI. Subsequently, Lactobacillus bacteremia occurred. Two independent blinded laboratory evaluations, using pulse field gel electrophoresis, 16S rRNA gene sequencing and DNA fingerprint analysis (rep-PCR), were performed to determine whether the recovered Lact. acidophilus originated from the probiotic product. Ultimately, the patient strain was identified as Lact. casei and both laboratories found no genetic relation between the patient's strain and any of the probiotic lactobacilli. This clinical case of lactobacillus bacteremia in the setting of probiotic exposure demonstrates the value of using discriminatory molecular methods to clearly determine whether there were a link between the patient's isolate and the probiotic strains.

Regional Epidemiology of Methicillin-Resistant Staphylococcus aureus Among Critically Ill Children in a State With Mandated Active Surveillance

BACKGROUND

In theory, active surveillance of methicillin-resistant Staphylococcus aureus (MRSA) reduces MRSA spread by identifying all MRSA-colonized patients and placing them under contact precautions. In October 2007, Illinois mandated active MRSA surveillance in all intensive care units, including neonatal intensive care units (NICUs) and pediatric intensive care units (PICUs). We evaluated MRSA trends in a large metropolitan region in the wake of this law.

METHODS

Chicago hospitals with a NICU or PICU were recruited for 8 single-day point prevalence surveys that occurred twice-yearly between June 2008 and July 2011 and then yearly in 2012 to 2013. Samples from all patients were cultured for MRSA (nose and umbilicus for neonates, nose and groin for pediatric patients). Hospital-reported admission MRSA-screening results also were obtained. Point prevalence cultures were screened for MRSA by using broth enrichment, chromogenic agar, and standard confirmatory methods.

RESULTS

All eligible hospitals (N = 10) participated (10 NICUs, 6 PICUs). Hospital-reported adherence to state-mandated MRSA screening at admission was high (95% for NICUs, 94% for PICUs). From serial point prevalence surveys, overall MRSA prevalences in the NICUs and PICUs were 4.2% (89 of 2101) and 5.7% (36 of 632), respectively. MRSA colonization prevalences were unchanged in the NICUs (year-over-year risk ratio [RR], 0.93 [95% confidence interval (CI), 0.78-1.12]; P = .45) and trended toward an increase in the PICUs (RR, 1.25 [95% CI, 0.72-2.12]; P = .053). We estimated that 81% and 40% of MRSA-positive patients in the NICUs and PICUs, respectively, had newly acquired MRSA.

CONCLUSIONS

In a region with mandated active MRSA surveillance, we found ongoing unchanged rates of MRSA colonization and acquisition among NICU and PICU patients.

Itch in the General Internal Medicine Setting: A Cross-Sectional Study of Prevalence and Quality-of-Life Effects

BACKGROUND

Itch is a well-established symptom in cutaneous disease. However, little is known about the burden of itch outside the dermatology setting.

PURPOSE

To determine the prevalence and impact of itch on quality of life (QOL) in the general internal medicine setting.

METHODS

We performed a cross-sectional study of 2076 adults from an outpatient general internal medicine clinic, using an audio computer-assisted self-administered interview. A history of itch (acute or chronic) and other physical symptoms in the past week, Patient-Reported Outcomes Measurement Information System (PROMIS) 10-item Global Health Questionnaire scores, and Patient Health Questionnaire-2 scores were assessed.

RESULTS

The prevalence of itch was 39.9 % and increased with age from 33.1 % at age 19-39 years to 45.9 % at age ≥80 years. In multivariable models controlled for socio-demographics, even feeling "a little" or "some" distress from itch was significantly associated with lower PROMIS global physical and mental health T-scores and estimated health utility scores (P ≤ 0.01). Further, feeling "quite a lot" of distress or "very much" distress from itch was associated with higher adjusted odds ratios for depressed mood (4.91 [95 % confidence interval (CI) 3.36-7.18]) and anhedonia (4.46 [95 % CI 3.07-6.47]). The patient burden of itch was similar to those of pain, constipation, sexual dysfunction, cough, and weight loss.

CONCLUSIONS

Itch occurs commonly in the primary care setting and is associated with poor QOL. Physicians should inquire about itch and its associations during review of systems. Future studies are needed to distinguish between the effects of acute and chronic itch.

Spread of Carbapenem-Resistant Enterobacteriaceae Among Illinois Healthcare Facilities: The Role of Patient Sharing

BACKGROUND

Carbapenem-resistant Enterobacteriaceae (CRE) spread regionally throughout healthcare facilities through patient transfer and cause difficult-to-treat infections. We developed a state-wide patient-sharing matrix and applied social network analyses to determine whether greater connectedness (centrality) to other healthcare facilities and greater patient sharing with long-term acute care hospitals (LTACHs) predicted higher facility CRE rates.

METHODS

We combined CRE case information from the Illinois extensively drug-resistant organism registry with measures of centrality calculated from a state-wide hospital discharge dataset to predict facility-level CRE rates, adjusting for hospital size and geographic characteristics.

RESULTS

Higher CRE rates were observed among facilities with greater patient sharing, as measured by degree centrality. Each additional hospital connection (unit of degree) conferred a 6% increase in CRE rate in rural facilities (relative risk [RR] = 1.056; 95% confidence interval [CI], 1.030-1.082) and a 3% increase among Chicagoland and non-Chicago urban facilities (RR = 1.027; 95% CI, 1.002-1.052 and RR = 1.025; 95% CI, 1.002-1.048, respectively). Sharing 4 or more patients with LTACHs was associated with higher CRE rates, but this association may have been due to chance (RR = 2.08; 95% CI, .85-5.08; P = .11).

CONCLUSIONS

Hospitals with greater connectedness to other hospitals in a statewide patient-sharing network had higher CRE burden. Centrality had a greater effect on CRE rates in rural counties, which do not have LTACHs. Social network analysis likely identifies hospitals at higher risk of CRE exposure, enabling focused clinical and public health interventions.

Electronic Public Health Registry of Extensively Drug-Resistant Organisms, Illinois, USA

In response to clusters of carbapenem-resistant Enterobacteriaceae (CRE) in Illinois, USA, the Illinois Department of Public Health and the Centers for Disease Control and Prevention Chicago Prevention Epicenter launched a statewide Web-based registry designed for bidirectional data exchange among health care facilities. CRE occurrences are entered and searchable in the system, enabling interfacility communication of patient information. For rapid notification of facilities, admission feeds are automated. During the first 12 months of implementation (November 1, 2013-October 31, 2014), 1,557 CRE reports (≈4.3/day) were submitted from 115 acute care hospitals, 5 long-term acute care hospitals, 46 long-term care facilities, and 7 reference laboratories. Guided by a state and local public health task force of infection prevention specialists and microbiologists and a nonprofit informatics entity, Illinois Department of Public Health deployed a statewide registry of extensively drug-resistant organisms. The legal, technical, and collaborative underpinnings of the system enable rapid incorporation of other emerging organisms.

Data requirements for electronic surveillance of healthcare-associated infections

Electronic surveillance for healthcare-associated infections (HAIs) is increasingly widespread. This is driven by multiple factors: a greater burden on hospitals to provide surveillance data to state and national agencies, financial pressures to be more efficient with HAI surveillance, the desire for more objective comparisons between healthcare facilities, and the increasing amount of patient data available electronically. Optimal implementation of electronic surveillance requires that specific information be available to the surveillance systems. This white paper reviews different approaches to electronic surveillance, discusses the specific data elements required for performing surveillance, and considers important issues of data validation.

When do patient-reported outcome measures inform readmission risk?

OBJECTIVE

To characterize changes in patient-reported outcome measures from hospital discharge to assess when they best inform risk of utilization as defined by readmissions or emergency department use.

PARTICIPANTS

Patients discharged from an urban safety-net hospital.

DESIGN

Longitudinal cohort study.

MAIN MEASURES

We serially administered the Memorial Symptom Assessment Scale (MSAS) and the PROMIS Global Health short form assessing General Self-Rated Health (GSRH), Global Physical (GPH), and Mental (GMH) Health at 0, 30, 90, and 180 days from hospital discharge. Time to first utilization from each survey was plotted by dichotomizing our sample on each patient-reported measure, and equivalence of the time-to-event curves was assessed using the log-rank test. Cox proportional hazard models were used to control for available covariates including prior utilization during the study, Charlson score, age, gender, and race/ethnicity. We assessed each measure's effect on the fit of the predictive models using the likelihood ratio test.

KEY RESULTS

We recruited 196 patients, of whom 100%, 98%, 90%, and 88% completed each respective survey wave. Participants' mean age was 52 years, 51% were women, 60% were non-Hispanic black, and 21% completed the questionnaires in Spanish. In-hospital assessments revealed high symptom burden and poor health status. In-hospital assessments of GMH and GSRH predicted 14-day reutilization, whereas posthospitalization assessments of MSAS and GPH predicted subsequent utilizations. Each measure selectively improved predictive model fit.

CONCLUSIONS

Routine measurement of patient-reported outcomes can help identify patients at higher risk for utilizations. At different time points, MSAS, GPH, GMH, and GSRH all informed utilization risk.

Implementation of an audio computer-assisted self-interview (ACASI) system in a general medicine clinic: patient response burden

BACKGROUND

Routine implementation of instruments to capture patient-reported outcomes could guide clinical practice and facilitate health services research. Audio interviews facilitate self-interviews across literacy levels.

OBJECTIVES

To evaluate time burden for patients, and factors associated with response times for an audio computer-assisted self interview (ACASI) system integrated into the clinical workflow.

METHODS

We developed an ACASI system, integrated with a research data warehouse. Instruments for symptom burden, self-reported health, depression screening, tobacco use, and patient satisfaction were administered through touch-screen monitors in the general medicine clinic at the Cook County Health & Hospitals System during April 8, 2011-July 27, 2012. We performed a cross-sectional study to evaluate the mean time burden per item and for each module of instruments; we evaluated factors associated with longer response latency.

RESULTS

Among 1,670 interviews, the mean per-question response time was 18.4 [SD, 6.1] seconds. By multivariable analysis, age was most strongly associated with prolonged response time and increased per decade compared to < 50 years as follows (additional seconds per question; 95% CI): 50-59 years (1.4; 0.7 to 2.1 seconds); 60-69 (3.4; 2.6 to 4.1); 70-79 (5.1; 4.0 to 6.1); and 80-89 (5.5; 4.1 to 7.0). Response times also were longer for Spanish language (3.9; 2.9 to 4.9); no home computer use (3.3; 2.8 to 3.9); and, low mental self-reported health (0.6; 0.0 to 1.1). However, most interviews were completed within 10 minutes.

CONCLUSIONS

An ACASI software system can be included in a patient visit and adds minimal time burden. The burden was greatest for older patients, interviews in Spanish, and for those with less computer exposure. A patient's self-reported health had minimal impact on response times.

Multicenter Intervention Program to Increase Adherence to Hand Hygiene Recommendations and Glove Use and to Reduce the Incidence of Antimicrobial Resistance

Objective.

To determine whether a multimodal intervention could improve adherence to hand hygiene and glove use recommendations and decrease the incidence of antimicrobial resistance in different types of healthcare facilities.

Design.

Prospective, observational study performed from October 1, 1999, through December 31, 2002. We monitored adherence to hand hygiene and glove use recommendations and the incidence of antimicrobial-resistant bacteria among isolates from clinical cultures. We evaluated trends in and predictors for adherence and preferential use of alcohol-based hand rubs, using multivariable analyses.

Setting.

Three intervention hospitals (a 660-bed acute and long-term care hospital, a 120-bed community hospital, and a 600-bed public teaching hospital) and a control hospital (a 700-bed university teaching hospital).

Intervention.

At the intervention hospitals, we introduced or increased the availability of alcohol-based hand rub, initiated an interactive education program, and developed a poster campaign; at the control hospital, we only increased the availability of alcohol-based hand rub.

Results.

We observed 6,948 hand hygiene opportunities. The frequency of hand hygiene performance or glove use significantly increased during the study period at the intervention hospitals but not at the control hospital; the maximum quarterly frequency of hand hygiene performance or glove use at intervention hospitals (74%, 80%, and 77%) was higher than that at the control hospital (59%). By multivariable analysis, preferential use of alcohol-based hand rubs rather than soap and water for hand hygiene was more likely among workers at intervention hospitals compared with nonintervention hospitals (adjusted odds ratio, 4.6 [95% confidence interval, 3.3-6.4]) and more likely among physicians (adjusted odds ratio, 1.4 [95% confidence interval, 1.2-1.8]) than among nurses at intervention hospitals. A significantly reduced incidence of antimicrobial-resistant bacteria among isolates from clinical culture was found at a single intervention hospital, which had the greatest increase in the frequency of hand hygiene performance.

Conclusions.

During a 3-year period, a multimodal intervention program increased adherence to hand hygiene recommendations, especially to the use of alcohol-based hand rubs. In one hospital, a concomitant reduction was found in the incidence of antimicrobial-resistant bacteria among isolates from clinical cultures.