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BackgroundIn 2005, pneumonia practice guidelines recommended broad-spectrum antibiotics for patients with risk factors for nosocomial pathogens. The impact of these recommendations on the ability of providers to match treatment with nosocomial pathogens is unknown.MethodsAmong hospitalizations with a principal diagnosis of pneumonia at 128 Department of Veterans Affairs medical centers from 2006 through 2010, we measured annual trends in antibiotic selection; initial blood or respiratory cultures positive for methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa, and Acinetobacter species; and alignment between antibiotic coverage and culture results for MRSA and P. aeruginosa, calculating sensitivity, specificity, and diagnostic odds ratio using a 2 × 2 contingency table.ResultsIn 95 511 hospitalizations for pneumonia, initial use of vancomycin increased from 16% in 2006 to 31% in 2010, and piperacillin-tazobactam increased from 16% to 27%, and there was a decrease in both ceftriaxone (from 39% to 33%) and azithromycin (change from 39% to 36%) (P < .001 for all). The proportion of hospitalizations with cultures positive for MRSA decreased (from 2.5% to 2.0%; P < .001); no change was seen for P. aeruginosa (1.9% to 2.0%; P = .14) or Acinetobacter spp. (0.2% to 0.2%; P = .17). For both MRSA and P. aeruginosa, sensitivity increased (from 46% to 65% and 54% to 63%, respectively; P < .001) and specificity decreased (from 85% to 69% and 76% to 68%; P < .001), with no significant changes in diagnostic odds ratio (decreases from 4.6 to 4.1 [P = .57] and 3.7 to 3.2 [P = .95], respectively).ConclusionsBetween 2006 and 2010, we found a substantial increase in the use of broad-spectrum antibiotics for pneumonia despite no increase in nosocomial pathogens. The ability of providers to accurately match antibiotic coverage to nosocomial pathogens remains low.

Background Carbapenem-resistant Enterobacteriaceae (CRE) cause approximately 13 100 infections, with an 8% mortality rate in the United States annually. Carbapenemase-producing CRE (CP-CRE) a subset of CRE infections infections have much higher mortality rates (40%–50%). There has been little research on characteristics unique to CP-CRE. The goal of the current study was to assess differences between US veterans with non-CP-CRE and those with CP-CRE cultures. Methods A retrospective cohort of veterans with CRE cultures from 2013–2018 and their demographic, medical, and facility level covariates were collected. Clustered multiple logistic regression models were used to assess independent factors associated with CP-CRE. Results The study included 3096 unique patients with cultures positive for either non-CP-CRE or CP-CRE. Being African American (odds ratio, 1.44 [95% confidence interval, 1.15–1.80]), diagnosis in 2017 (3.11 [2.13–4.54]) or 2018 (3.93 [2.64–5.84]), congestive heart failure (1.35 [1.11–1.64]), and gastroesophageal reflux disease (1.39 [1.03–1.87]) were associated with CP-CRE cultures. There was no known antibiotic exposure in the previous year for 752 patients (24.3% of the included patients). Those with no known antibiotic exposure had increased frequency of prolonged proton pump inhibitor use (17.3%) compared to those with known antibiotic exposure (5.6%). Discussion Among a cohort of patients with CRE, African Americans, patients with congestive heart failure, and those with gastroesophageal reflux disease had greater odds of having a CP-CRE culture. Roughly 1 in 4 patients with CP-CRE had no known antibiotic exposure in the year before their positive culture. [ABSTRACT FROM AUTHOR]

Background In October 2007, Veterans Affairs (VA) launched a nationwide effort to reduce methicillin-resistant Staphylococcus aureus (MRSA) transmission called the National MRSA Prevention Initiative. Although the initiative focused on MRSA, recent evidence suggests that it also led to a significant decrease in hospital-onset (HO) gram-negative rod (GNR) bacteremia, vancomycin-resistant Enterococci (VRE), and Clostridioides difficile infections. The objective of this analysis was to evaluate the cost-effectiveness and the budget impact of the initiative taking into account MRSA, GNR, VRE, and C. difficile infections. Methods We developed an economic model using published data on the rate of MRSA hospital-acquired infections (HAIs) and HO-GNR bacteremia in the VA from October 2007 to September 2015, estimates of the attributable cost and mortality of these infections, and the costs associated with the intervention obtained through a microcosting approach. We explored several different assumptions for the rate of infections that would have occurred if the initiative had not been implemented. Effectiveness was measured in life-years (LYs) gained. Results We found that during fiscal years 2008–2015, the initiative resulted in an estimated 4761–9236 fewer MRSA HAIs, 1447–2159 fewer HO-GNR bacteremia, 3083–3602 fewer C. difficile infections, and 2075–5393 fewer VRE infections. The initiative itself was estimated to cost $561 million over this 8-year period, whereas the cost savings from prevented MRSA HAIs ranged from $165 to $315 million and from prevented HO-GNR bacteremia, CRE and C. difficile infections ranged from $174 to $200 million. The incremental cost-effectiveness of the initiative ranged from $12 146 to $38 673/LY when just including MRSA HAIs and from $1354 to $4369/LY when including the additional pathogens. The overall impact on the VA's budget ranged from $67 to$195 million. Conclusions An MRSA surveillance and prevention strategy in VA may have prevented a substantial number of infections from MRSA and other organisms. The net increase in cost from implementing this strategy was quite small when considering infections from all types of organisms. Including spillover effects of organism-specific prevention efforts onto other organisms can provide a more comprehensive evaluation of the costs and benefits of these interventions. [ABSTRACT FROM AUTHOR]

Background Vancomycin is now a preferred treatment for all cases of Clostridioides difficile infection (CDI), regardless of disease severity. Concerns remain that a large-scale shift to oral vancomycin may increase selection pressure for vancomycin-resistant Enterococci (VRE). We evaluated the risk of VRE following oral vancomycin or metronidazole treatment among patients with CDI. Methods We conducted a retrospective cohort study of patients with CDI in the US Department of Veterans Affairs health system between 1 January 2006 and 31 December 2016. Patients were included if they were treated with metronidazole or oral vancomycin and had no history of VRE in the previous year. Missing data were handled by multiple imputation of 50 datasets. Patients treated with oral vancomycin were compared to those treated with metronidazole after balancing on patient characteristics using propensity score matching in each imputed dataset. Patients were followed for VRE isolated from a clinical culture within 3 months. Results Patients treated with oral vancomycin were no more likely to develop VRE within 3 months than metronidazole-treated patients (adjusted relative risk, 0.96; 95% confidence interval [CI],.77 to 1.20), equating to an absolute risk difference of −0.11% (95% CI, −.68% to.47%). Similar results were observed at 6 months. Conclusions Our results suggest that oral vancomycin and metronidazole are equally likely to impact patients' risk of VRE. In the setting of stable CDI incidence, replacement of metronidazole with oral vancomycin is unlikely to be a significant driver of increased risk of VRE at the patient level. In this multicenter, retrospective cohort study of patients with Clostridioides difficile infection, the use of oral vancomycin did not increase the risk of vancomycin-resistant Enterococci infection at 3 or 6 months compared to metronidazole. [ABSTRACT FROM AUTHOR]

Background The Department of Veterans Affairs implemented an active surveillance program for methicillin-resistant Staphylococcus aureus (MRSA) in 2007 in which acute care inpatients are tested for MRSA carriage on admission, unit-to-unit transfer, and discharge. Using these data, we followed patients longitudinally to estimate the difference in infection rates for those who were not colonized, those who were colonized on admission (importers), and those who acquired MRSA during their stay. We examined MRSA infections that occurred prior to discharge and at 30, 90, 180, and 365 days after discharge. Methods We constructed a dataset of 985626 first admissions from January 2008 through December 2015 who had surveillance tests performed for MRSA carriage. We performed multivariable Cox proportional hazards and logistic regression models to examine the relationship between MRSA colonization status and infection. Results The MRSA infection rate across the predischarge and 180-day postdischarge time period was 5.5% in importers and 7.0% in acquirers without a direct admission to the intensive care unit (ICU) and 11.4% in importers and 11.7% in acquirers who were admitted directly to the ICU. The predischarge hazard ratio for MRSA infection was 29.6 (95% confidence interval [CI], 26.5–32.9) for importers and 28.8 (95% CI, 23.5–35.3) for acquirers compared to those not colonized. Fully 63.9% of all MRSA pre- and postdischarge infections among importers and 61.2% among acquirers occurred within 180 days after discharge. Conclusions MRSA colonization significantly increases the risk of subsequent MRSA infection. In addition, a substantial proportion of MRSA infections occur after discharge from the hospital. [ABSTRACT FROM AUTHOR]

We demonstrated empirical evidence for a conceptual model of how methicillin-resistant Staphylococcus aureus (MRSA) importation, transmission, and nosocomial infection relate to each other. Decreases in MRSA transmission and importation were strongly associated with decreases in nosocomial infection.Background. The study of hospital methicillin-resistant Staphylococcus aureus (MRSA) epidemiology is complicated by its transmissibility. Our objective was to understand how MRSA importation and transmission influence MRSA nosocomial infections in Veterans Affairs Medical Centers (VAMCs).Methods. We performed hospital-level analyses of acute-care MRSA admission prevalence, acquisition rates, and incident nosocomial clinical culture (INCC) rates, each a surrogate measure of importation, transmission, and nosocomial infection, respectively. We studied 112 VAMCs from October 2007 through September 2010, after the start of a bundled intervention including active surveillance for MRSA. We analyzed data using generalized linear mixed models.Results. A total of 2.9 million surveillance tests were collected from 1.4 million patient admissions. Overall MRSA admission prevalence was 11.4%, acquisition was 5.2 per 1000 patient-days at risk, and INCC was 1.8 per 1000 patient-days at risk. A 10% increase in a hospital's average admission prevalence was associated with a 9.7% increase in its weekly acquisition rates (P < .001) and a 9.8% increase in its weekly INCC rates (P < .001). Significant decreases were observed in all 3 measures during the study period (P < .001). When INCC rates were stratified by nasal MRSA carriage at admission, a significant downward trend was observed only among those initially negative.Conclusions. Measured associations between MRSA admission prevalence, acquisition rate, and INCC rate were consistent with the hypothesis that decreased acquisition led to decreased importation, which in turn further abated acquisition. The downward trend in INCC rate specifically among individuals with negative admission surveillance tests suggests that decreasing transmission contributed to lower rates of nosocomial MRSA infection. [ABSTRACT FROM PUBLISHER]

Analysis of Medicare claims data show that infectious diseases (ID) specialist care of patients with infections is associated with better outcomes and lower cost of care. These benefits are greatest when ID specialist involvement begins within 2 days of hospital admission.Background. Previous studies, largely based on chart reviews with small sample sizes, have demonstrated that infectious diseases (ID) specialists positively impact patient outcomes. We investigated how ID specialists impact mortality, utilization, and costs using a large claims dataset.Methods. We used administrative fee-for-service Medicare claims to identify beneficiaries hospitalized from 2008 to 2009 with at least 1 of 11 infections. There were 101 991 stays with and 170 336 stays without ID interventions. Cohorts were propensity score matched for patient demographics, comorbidities, and hospital characteristics. Regression models compared ID versus non-ID intervention and early versus late ID intervention. Risk-adjusted outcomes included hospital and intensive care unit (ICU) length of stay (LOS), mortality, readmissions, hospital charges, and Medicare payments.Results. The ID intervention cohort demonstrated significantly lower mortality (odds ratio [OR], 0.87; 95% confidence interval [CI], .83 to .91) and readmissions (OR, 0.96; 95% CI, .93 to .99) than the non-ID intervention cohort. Medicare charges and payments were not significantly different; the ID intervention cohort ICU LOS was 3.7% shorter (95% CI, −5.5% to −1.9%). Patients receiving ID intervention within 2 days of admission had significantly lower 30-day mortality and readmission, hospital and ICU length of stay, and Medicare charges and payments compared with patients receiving later ID interventions.Conclusions. ID interventions are associated with improved patient outcomes. Early ID interventions are also associated with reduced costs for Medicare beneficiaries with select infections. [ABSTRACT FROM PUBLISHER]

Agreement among multiple infection preventionists performing conventional surveillance for bloodstream infections and as compared with a laboratory-based algorithmic approach was evaluated. Classifications by infection preventionists varied significantly from each other, with a trend for better agreement with the algorithm. Algorithms may be preferred when the goal is to compare facilities.Background. Mandatory reporting of healthcare-associated infections (HAIs) is increasing. Evidence for agreement among different reviewers applying HAI surveillance criteria is limited. We aim to characterize agreement among infection preventionists (IPs) conducting surveillance for central line–associated bloodstream infection (CLABSI) with each other and as compared with simplified laboratory-based definitions.Methods. Abstracted electronic health records were assembled from inpatients with positive blood cultures at a tertiary-care Veterans Affairs (VA) hospital over a 5-year period. Identical patient records were made available to VA IPs from different facilities to report on CLABSI using their usual surveillance methods. Positive blood cultures were also evaluated using laboratory-based definitions. Standard indices of interrater agreement, expressed as a κ statistic, were computed between IPs, and between IPs and simplified laboratory-based methods.Results. Overall, 114 patient records were reviewed by 18 IPs, the majority of whom specified they followed National Healthcare Safety Network criteria. The overall agreement among IPs by κ statistic was 0.42 (standard error [SE], 0.06). IPs had better agreement with a simple laboratory-based definition with an average κ of 0.55 (SE, 0.05). The proportion of patient records that 18 IPs reported with CLABSI ranged from 14% to 39% (overall mean, 28% with a coefficient of variation of 25%). When simple laboratory-based methods were applied to different sets of patient records, classification was more consistent with CLABSI assigned in a proportion ranging from 36% to 42% (overall mean, 39%).Conclusions. Reliability of IP-conducted surveillance to identify HAI may not be ideal for public reporting goals of interhospital comparisons. [ABSTRACT FROM PUBLISHER]