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Background: Guidelines for treatment of resistant Acinetobacter baumannii (AB) are limited, leaving a knowledge gap in best practices for treatment. This study described treatments and outcomes of extensively-drug resistant (XDR) AB., Methods: Retrospective cohort study including patients with XDRAB (non-susceptible to at least 1 agent in all but 2 or fewer classes) and antibiotic treatment between 2012 and 2018 at Veterans Affairs Medical Centers. Descriptive statistics summarized antibiotics; propensity score adjusted regression models were fit to compare outcomes., Results: Two hundred and seventy-six patients with 439 XDRAB cultures and Gram-negative targeted antibiotic treatment were included. One hundred and eighteen (43%) patients received monotherapy while 158 (57%) received combination therapy, most commonly including a carbapenem (n = 106, 67%) and polymyxin (n = 66, 42%). One hundred and eighty-four (67%) patients received inadequate treatment. In adjusted models, combination therapy did not decrease the odds of in-hospital (aOR 1.24, 95%CI 0.60-2.59) or 30-day (aOR 1.43, 95%CI 0.86-2.38) mortality, or median postculture length of stay (aIRR 1.11, 95%CI 0.86-1.43). Likewise, receipt of inadequate treatment was not associated with poorer outcomes., Conclusions: In this national cohort of patients with XDRAB, neither combination therapy nor receipt of adequate treatment improved outcomes. Further research is needed on optimal management of this difficult-to-treat pathogen with few effective antibiotic options., (Published by Elsevier Inc.)

Background: SARS-CoV-2 has spread rapidly resulted in a global pandemic and public health crisis. The internet is a frequently used resource for providing patient education materials (PEMs). The aim of this study was to evaluate the readability, content, and quality of web-based PEMs on COVID-19 from US academic medical centers., Methods: The names of US medical schools were obtained from the Association of American Medical Colleges website (n = 145). Institutional, hospital, and heath encyclopedia websites associated with each schools' medical center were identified using Google. Readability of COVID-19 PEMs was calculated using three validated indices: (1) Flesh-Kincaid Grade Level, (2) Simple Measure of Gobbledygook, and (3) Gunning Frequency of Gobbledygook. Content was evaluated using a scoring matrix based on materials available on the Center for Disease Control website. The Patient Education Material Assessment Tool for Print (PEMAT-P) was used to assess usability and actionability., Results: A total of 141 (97%) PEMs met inclusion criteria and were analyzed for readability, content, and quality. The mean readability was above the recommended sixth grade reading level (P < .001). Content was variable across PEMs. The PEMAT-P scores reflected good understandability with a median score of 83% (IQR 75%-87%), while actionability was poor with a median score of 41% (IQR 40%-60%)., Conclusions: Despite availability of web-based PEMs for COVID-19, the readability was significantly higher than the National Institute of Health and US Department of Health and Human Services recommended sixth grade reading level and actionability of PEMs was low. It is critical to provide readable PEMs on COVID-19 to effectively disseminate accurate information and facilitate patients' understanding of the virus, how it spreads, and how to protect themselves., (Copyright © 2020 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Primary prevention of Clostridioides (Clostridium) difficile infections (CDI) is an important but challenging infection control goal for hospitals and health care facilities. Enhanced infection control protocols have reduced CDI rates, but the problem persists and administration of probiotics to patients at risk could be very useful if shown to be safe and effective. Randomized controlled trials are largely impractical for primary prevention CDI trials due to large required study sizes and quasi-experimental studies are becoming more frequent as a method to assess this problem., Objective: Our goal is to review the published quasi-experimental studies adding probiotics to their infection control protocols to reduce CDI and determine the strengths and limitations for this type of study design., Methods: The literature was searched using PubMed, Google Scholar, Medline and Cochrane Databases and gastrointestinal meeting abstracts from January 2000 to January 2020 for quasi-experimental intervention studies testing various probiotics for the primary prevention of CDI., Results: We found 28 studies with 7 different types of probiotics (10 studies implementing a hospital-wide intervention, 6 studies targeting 1-3 wards, and 12 studies on either sustainability, cost-effectiveness or subgroup analysis). Some probiotics demonstrated a significant reduction in CDI rates; all four of the probiotic types given only on specific wards and 3 of the 4 probiotics given facility-wide. However, this type of study design was influenced by numerous factors which must be carefully accounted for in the analysis., Conclusions: Some probiotics may be an effective addition to infection control protocols to prevent C. difficile infections, but careful study design considerations are needed., (Copyright © 2020 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Patients with spinal cord injury (SCI) have a high risk for multidrug-resistant organisms, including carbapenem-resistant Enterobacteriaceae (CRE). Accurate and easily applied definitions are critical to identify CRE. This study describes CRE and associated characteristics in veterans with SCI per Centers for Disease Control and Prevention (CDC) and Department of Veterans Affairs (VA) definitions., Methods: A retrospective cohort of veterans with SCI and more than 1 culture with Escherichia coli, Klebsiella spp and/or Enterobacter spp between 2012 and 2013 was examined. Antibiotic susceptibility criteria of pre-2015 (CDC1) and post-2015 (CDC2) CDC definitions and pre-2017 (VA1) and post-2017 (VA2) VA definitions were used to identify CRE. CRE prevalence and characteristics are described for isolates meeting each definition, and agreement was assessed with the Cohen kappa., Results: We reviewed 21,514 isolates cultured from 6,974 veterans; 423 isolates met any CRE definition. Although agreement among definitions was high (kappa = 0.82-0.93), definitions including ertapenem resistance led to higher CRE prevalence (VA1 = 1.7% and CDC2 = 1.9% vs VA2 = 1.4% and CDC1 = 1.5%). Forty-four of 142 VA facilities had more than 1 CRE case defined by VA2; 10 facilities accounted for 60% of CRE cases. Almost all CRE was isolated from high-complexity, urban facilities, and the South had the highest proportion of CRE., Conclusions: Varying federal definitions give different CRE frequencies in a high-risk population. Definitions including ertapenem resistance resulted in higher CRE prevalence but may overemphasize noncarbapenemase isolates. Thus, both federal definitions now highlight the importance of carbapenemase testing., (Published by Elsevier Inc.)

Background: Multidrug-resistant (MDR) Acinetobacter is a growing concern and has been identified as a serious threat by the Centers for Disease Control and Prevention. However, there is little information on MDR Acinetobacter in individuals with spinal cord injuries and disorders (SCI/Ds). Therefore, the objective of this study was to identify risk factors for, and assess outcomes of, MDR Acinetobacter in veterans with SCI/Ds., Methods: This was a retrospective cohort study from January 1, 2012-December 31, 2013, using national Veterans Affairs medical encounter and microbiology data., Results: A total of 773 Acinetobacter cultures were identified in 571 patients, of which 58.9% were MDR. Inpatient culture, sputum and other specimen type, receipt of antibiotics within 90 days before culture date, and pressure ulcers were identified as independent predictors of MDR Acinetobacter. Highest odds of MDR Acinetobacter were seen with previous antibiotic use (odds ratio, 7.27; 95% confidence interval, 2.59-20.54). Thirty-day mortality was 5.3% in this study. Multidrug resistance, previous mechanical ventilation 90 days before the culture, and cancer were all independent risk factors for 30-day mortality., Conclusions: There should be increased efforts to highlight the importance of antimicrobial stewardship to improve infection control to help limit spread of Acinetobacter in health care settings., (Published by Elsevier Inc.)

This practice forum reports experiences with the development of a unit-specific antibiogram and planning for its implementation. Involvement of internal and external facilitators was a key strategy for addressing issues, including data limitations, coordination, and planning. These activities were incorporated and reported as part of the facility's broader antimicrobial stewardship program, and represent the first step in a set of planned projects to evaluate the impact of antibiograms on provider behavior and patient outcomes., (Published by Elsevier Inc.)

Background: Health care worker (HCW) vaccination rates have been low for many years (approximately 50%). Our goal was to implement an influenza declination form program (DFP) to assess feasibility, participation, HCW vaccination, and costs., Methods: This was a prospective interventional pilot study using mixed methods to evaluate the DFP implementation processes and outcomes. We conducted a formative evaluation and interviews; data were transcribed and coded into themes. Secondary outcomes included self-reported HCW influenza vaccine uptake (pre-/postsurvey) and program costs; data were evaluated using descriptive and bivariate analyses., Results: The DFP was compatible with ongoing strategies and unit culture. Barriers included multiple hospital shifts and competing demands. Facilitators included complementary ongoing strategies and leadership engagement. HCW vaccination rates were higher post- versus preimplementation (77.4% vs 53.5%, P =.01). To implement the DFP at site 1, using a mobile flu cart, 100% of declination forms were completed in 42.5 staff hours over <2 months. At site 2, using a vaccination table on all staff meeting days, 49% of forms were completed in 26.5 staff hours over 4.5 months. Average cost of staff time was $2,093 per site., Conclusion: DFP implementation required limited resources and resulted in increased HCW influenza vaccine rates; this may have positive clinical implications for influenza infection control/prevention., (Published by Elsevier Inc.)

The objective of this analysis was to understand the relationship between knowledge and attitudes regarding methicillin-resistant Staphylococcus aureus and hand hygiene behavior based on a baseline survey administered to Veterans with spinal cord injuries and disorders. Higher knowledge was associated with higher attitude scores (r = 0.35, P = .003), but knowledge and attitudes were not associated with behavior. Also, those with quadriplegia had higher knowledge scores (P = .03). Knowledge and attitudes, although related, do not appear to fully explain patients' hand hygiene behavior., (Published by Elsevier Inc.)

Background: The goal of this study was to assess current practices for training of spinal cord injury and disorder (SCI/D) health care workers and education of veterans with SCI/D in Department of Veterans Affairs (VA) spinal cord injury (SCI) centers on methicillin-resistant Staphylococcus aureus (MRSA) prevention., Methods: Mixed methods. A Web-based survey was distributed to 673 VA SCI/D providers across 24 SCI centers; 21 acute care and 1 long-term care facility participated. There were 295 that responded, 228 had complete data and were included in this analysis. Semistructured interviews were conducted with 30 SCI/D providers across 9 SCI centers., Results: Nurses, physicians, and therapists represent most respondents (92.1%, n = 210); over half (56.6%, n = 129) were nurses. Of providers, 75.9% (n = 173) reported receiving excellent or good training on how to educate patients about MRSA. However, nurses were more likely to report having excellent or good training for how to educate patients about MRSA (P = .005). Despite this, only 63.6% (n = 82) of nurses perceived the education they provide patients on how MRSA is transmitted as excellent or good., Conclusion: Despite health care workers reporting receiving excellent or good training on MRSA-related topics, this did not translate to excellent or good education for patients, suggesting that health care workers need additional training for educating patients. Population-specific MRSA prevention educational materials may also assist providers in educating patients about MRSA prevention for individuals with SCI/D., (Published by Mosby, Inc.)

Background: Recurrent Clostridium difficile (CDI) infection is a growing concern; however, there are little data on impact of recurrent CDI on those with spinal cord injury and disorder (SCI/D). Therefore, the objective of this study was to identify risk factors associated with recurrence of CDI among Veterans with SCI/D., Methods: This was a retrospective cohort study with data from outpatient, inpatient, and extended care settings at 83 Department of Veterans Affairs facilities from 2002 to 2009., Results: Of 1,464 cases of CDI analyzed, 315 cases (21.5%) had a first recurrence of CDI. Multivariable regression demonstrated that risk factors significantly associated with increased recurrence were concomitant fluoroquinolone use (odds ratio [OR], 1.39; 95% confidence interval [CI]: 1.08-1.80), whereas concomitant tetracycline use (OR, 0.35; 95% CI: 0.14-0.90), and cerebrovascular accident (OR, 0.46; 95% CI: 0.25-0.85) were associated with decreased recurrence. A subanalysis in those with health care facility-onset CDI showed that increased length of stay postinitial CDI was a significant risk factor for recurrence as was concomitant use of fluoroquinolones and that tetracycline remained protective for recurrence., Conclusion: Concomitant fluoroquinolone use was a risk factor for the recurrence of CDI. In contrast, tetracyclines and cerebrovascular accident were protective. Length of stay greater than 90 days from the initial CDI episode was also a risk factor for recurrence among those with health care facility-onset CDI. Future studies should focus on effective strategies to prevent these risk factors among the SCI/D population., (Published by Mosby, Inc.)

Background: Methicillin-resistant Staphylococcus aureus (MRSA) health care-associated infections (HAIs) are a concern in the 22 acute care Veterans Affairs (VA) spinal cord injury units where patients with unique rehabilitation and medical needs and a high risk of infection are treated., Methods: A bundle was implemented in VA spinal cord injury units consisting of nasal surveillance for MRSA on admission/in-hospital transfer/discharge, contact precautions for patients colonized or infected with MRSA, an emphasis on hand hygiene, and an institutional culture change where infection control became everyone's responsibility., Results: From October 2007, through June 2011, there were 51,627 admissions/transfers/discharges and 816,254 patient-days of care in VA spinal cord injury units. The percentage of patients screened increased to >95.0%. The mean admission MRSA prevalence was 38.6% ± 19.1%. Monthly HAI rates declined 81% from 1.217 per 1,000 patient-days to 0.237 per 1,000 patient-days (P < .001). Bloodstream infections declined by 100% (P = .002), skin and soft-tissue infections by 60% (P = .007), and urinary tract infections by 33% (P = .07)., Conclusion: Universal surveillance, contact precautions, hand hygiene, and an institutional culture change was associated with significant declines in MRSA HAIs in a setting with a high prevalence of MRSA colonization and a high risk for infection., (Published by Mosby, Inc.)

Background: Nosocomial infection may contribute to poor long-term consequences in persons who have spinal cord injuries and disorders (SCI&D)., Methods: This is a cohort study of individuals who had SCI&D and were hospitalized at least once during 2002. They were followed for 3 years to assess inpatient (IP) admissions, total IP length of stay (LOS), outpatient (OP) visits, and mortality. Count data models and a Cox proportional hazards model were used to assess the relationship between previous infection and subsequent IP and OP use and long-term mortality, respectively., Results: Of persons who had SCI&D, 59% had at least one nosocomial infection. Multivariable regression indicated that veterans who had SCI&D had more IP admissions (b = 0.405; P < .0001) and longer IP LOS (b = 0.843; P < .0001) if they had a previous infection; however, infection status was not a predictor of future OP visits. Survival time was lower (913.93 versus 1034.75 days, P = .004) in the infection group. Death rate was higher in the nosocomial infection group (30.11% versus 10.77%; P = .004), but the association did not achieve significance in the Cox proportional hazards model (P = .12)., Conclusions: Nosocomial infections have serious subsequent consequences that result in future hospitalization and shorter survival. Efforts to prevent nosocomial infections are needed to reduce long-term adverse effects in persons who have SCI&D.

Background: This study examines the hypothesis that the exaggerated splanchnic release of prostacyclin is due to new synthesis of both cyclooxygenase and prostacyclin synthase (PS) in the ileum muscularis/serosa., Methods: Sprague-Dawley rats were anesthetized and subjected to acute hemorrhage to 30 mm Hg for 30 minutes (shock) or sham shock. The superior mesenteric artery (SMA) was cannulated and removed with its end-organ intestine and perfused in vitro with Krebs-Henseleit buffer with and without cycloheximide (50 micrograms/ml) or indomethacin (20 micrograms/ml). Venous effluent was analyzed for eicosanoids by radioimmunoassay. The SMA, aorta and ileal mucosa, and muscularis/serosa were analyzed for PS and cyclooxygenase content by immunoblot analysis., Results: The sham splanchnic bed released threefold more 6-keto-PGF1 alpha than prostaglandin E2 and thromboxane. Acute ischemia increased splanchnic release of 6-keto-PGF1 alpha threefold compared with sham, which was abolished by cycloheximide or indomethacin treatment. Acute ischemia increased content of PS and cyclooxygenase in the ileal muscularis/serosa twofold and PS in the aorta and SMA by 50%., Conclusions: Acute ischemia increased release of 6-keto-PGF1 alpha, which was dependent on new protein synthesis. The immunoblot data suggest that the location of the increased enzymes responsible for increased 6-keto-PGF1 alpha release is the ileal muscularis/serosa and in the aorta and SMA.