Becky Smith

Severe influenza in 33 US hospitals, 2013–2014: Complications and risk factors for death in 507 patients

BACKGROUND Influenza A (H1N1) pdm09 became the predominant circulating strain in the United States during the 2013-2014 influenza season. Little is known about the epidemiology of severe influenza during this season. METHODS A retrospective cohort study of severely ill patients with influenza infection in intensive care units in 33 US hospitals from September 1, 2013, through April 1, 2014, was conducted to determine risk factors for mortality present on intensive care unit admission and to describe patient characteristics, spectrum of disease, management, and outcomes. RESULTS A total of 444 adults and 63 children were admitted to an intensive care unit in a study hospital; 93 adults (20.9%) and 4 children (6.3%) died. By logistic regression analysis, the following factors were significantly associated with mortality among adult patients: older age (>65 years, odds ratio, 3.1 [95% CI, 1.4-6.9], P=.006 and 50-64 years, 2.5 [1.3-4.9], P=.007; reference age 18-49 years), male sex (1.9 [1.1-3.3], P=.031), history of malignant tumor with chemotherapy administered within the prior 6 months (12.1 [3.9-37.0], P<.001), and a higher Sequential Organ Failure Assessment score (for each increase by 1 in score, 1.3 [1.2-1.4], P<.001). CONCLUSION Risk factors for death among US patients with severe influenza during the 2013-2014 season, when influenza A (H1N1) pdm09 was the predominant circulating strain type, shifted in the first postpandemic season in which it predominated toward those of a more typical epidemic influenza season.

Bacterial and viral co-infections complicating severe influenza: Incidence and impact among 507 U.S. patients, 2013–14

Abstract Background Influenza acts synergistically with bacterial co-pathogens. Few studies have described co-infection in a large cohort with severe influenza infection. Objectives To describe the spectrum and clinical impact of co-infections. Study design Retrospective cohort study of patients with severe influenza infection from September 2013 through April 2014 in intensive care units at 33 U.S. hospitals comparing characteristics of cases with and without co-infection in bivariable and multivariable analysis. Results Of 507 adult and pediatric patients, 114 (22.5%) developed bacterial co-infection and 23 (4.5%) developed viral co-infection. Staphylococcus aureus was the most common cause of co-infection, isolated in 47 (9.3%) patients. Characteristics independently associated with the development of bacterial co-infection of adult patients in a logistic regression model included the absence of cardiovascular disease (OR 0.41 [0.23–0.73], p=0.003), leukocytosis (>11K/μl, OR 3.7 [2.2–6.2], p<0.001; reference: normal WBC 3.5–11K/μl) at ICU admission and a higher ICU admission SOFA score (for each increase by 1 in SOFA score, OR 1.1 [1.0–1.2], p=0.001). Bacterial co-infections (OR 2.2 [1.4–3.6], p=0.001) and viral co-infections (OR 3.1 [1.3–7.4], p=0.010) were both associated with death in bivariable analysis. Patients with a bacterial co-infection had a longer hospital stay, a longer ICU stay and were likely to have had a greater delay in the initiation of antiviral administration than patients without co-infection (p<0.05) in bivariable analysis. Conclusions Bacterial co-infections were common, resulted in delay of antiviral therapy and were associated with increased resource allocation and higher mortality.

Antimicrobial Stewardship Lessons From Mupirocin Use and Resistance in Methicillin-Resitant Staphylococcus Aureus

Abstract Background The quantitative relationship between antimicrobial agent consumption and rise or fall of antibiotic resistance has rarely been studied. We began all admission surveillance testing for methicillin-resistant Staphylococcus aureus (MRSA) in August 2005 with subsequent contact isolation and decolonization using nasally applied mupirocin ointment for those colonized. In October 2012, we discontinued decolonization of medical (nonsurgical service) patients. Methods We conducted a retrospective study from 2007 through 2014 of 445680 patients; 35235 were assessed because of mupirocin therapy and positive test results for MRSA. We collected data on those patients receiving 2% mupirocin ointment for decolonization to determine the defined daily doses (DDDs). A nonparametric regression technique was used to quantitate the effect of mupirocin consumption on drug resistance in MRSA. Results Using regressive modeling, we found that, when consumption was consistently >25 DDD/1000 patient-days, there was a statistically significant increase in mupirocin resistance with a correlating positive rate of change. When consumption was ≤25 DDD/1000 patient-days, there was a statistically significant decrease in mupirocin resistance with a correlating negative rate of change. The scatter plot of fitted versus observed mupirocin resistance values showed an R2 value of 0.89—a high correlation between mupirocin use and resistance. Conclusions Use of the antimicrobial agent mupirocin for decolonization had a threshold of approximately 25 DDD/1000 patient-days that separated a rise and fall of resistance within the acute-care setting. This has implications for how widely mupirocin can be used for decolonization, as well as for setting consumption thresholds when prescribing antimicrobials as part of stewardship programs.

Reduction of methicillin-resistant Staphylococcus aureus infection in long-term care is possible while maintaining patient socialization: A prospective randomized clinical trial

BACKGROUND Antibiotic resistance is a challenge in long-term care facilities (LTCFs). The objective of this study was to demonstrate that a novel, minimally invasive program not interfering with activities of daily living or socialization could lower methicillin-resistant Staphylococcus aureus (MRSA) disease. METHODS This was a prospective, cluster-randomized, nonblinded trial initiated at 3 LTCFs. During year 1, units were stratified by type of care and randomized to intervention or control. In year 2, all units were converted to intervention consisting of universal decolonization using intranasal mupirocin and a chlorhexidine bath performed twice (2 decolonization-bathing cycles 1 month apart) at the start of the intervention period. Subsequently, after initial decolonization, all admissions were screened on site using real-time polymerase chain reaction, and those MRSA positive were decolonized, but not isolated. Units received annual instruction on hand hygiene. Enhanced bleach wipe cleaning of flat surfaces was done every 4 months. RESULTS There were 16,773 tests performed. The MRSA infection rate decreased 65% between baseline (44 infections during 365,809 patient days) and year 2 (12 infections during 287,847 patient days; P <.001); a significant reduction was observed at each of the LTCFs (P <.03). CONCLUSIONS On-site MRSA surveillance with targeted decolonization resulted in a significant decrease in clinical MRSA infection among LTCF residents.

To Be a CLABSI or Not to Be a CLABSI—That is the Question: The Epidemiology of BSI in a Large ECMO Population

identified venues to receive this education. Nurses with master’s degrees were less likely to believe that nurses might play a role in ASPs, perhaps due to greater familiarity with the current state of ASP, and perhaps, therefore, they were less likely to think “outside the box” regarding a nursing role. Nonetheless, most nurses felt that they played a role in antimicrobial stewardship. The strengths of this study include the large number of nursing respondents across different hospitals and patient care units. The study also has several limitations. The survey had a relatively low response rate, and because responses to the survey were voluntary, respondents may not be representative of all nurses at our hospital system. Similarly, responses obtained from nurses in our institution may not be generalizable among all nurses. This study illustrates a need to educate nurses on general principles of antimicrobial stewardship, and our findings point to multiple areas for nursing-targeted interventions that merit additional research. Nurses could ensure or facilitate acquisition of proper allergy histories, blood culture techniques, prioritization of antimicrobial administration, and antimicrobial de-escalation. Given the number of bedside nurses in practice, such interventions have the potential to substantially lower inappropriate antimicrobial utilization.

1035New Urine Reporting Criteria to Accurately Report Nosocomial Clinical Urinary Tract Infection

Background. Reducing unnecessary antimicrobial therapy is critical to patient safety. We previously conducted an analysis to establish a colony count threshold predicting clinically significant UTI developing in hospitalized patients (AJCP 2012;137:778-84). Patients with urine culture colony counts >10 CFU/ml were 74 times more likely to have a clinically significant UTI than patients with colony counts <10 CFU/ml. With the approval of the Departments of Urology, Infectious Disease, Quality, and Infection Control we modified our urine culture laboratory reporting criteria for voided and Foley catheter samples from hospitalized patients with a length of stay of >2 days. For these patients, a positive test consists of 1-2 organisms at >10CFU/ml. Any other colony count or mixture of bacteria is reported as “Negative for Nosocomial UTI” (NNUTI). We hypothesize that this new reporting scheme would accurately report the absence of a UTI in >95% of samples. The first 5 months of the new reporting approach was validated with chart review. Methods. Inpatient urine cultures were assessed to determine if 1) a patient had been in the hospital >2 days when the culture was taken and 2) the urine was a voided or Foley sample. The culture report was assessed with chart review by a single Infectious Disease Physician to determine if the patient had signs and symptoms of a UTI when NNUTI was the result. Parameters to determine UTI included fever >100.4°F, frequency, dysuria, or flank pain, and change in clinical status with no other reason other than UTI. A negative urinalysis and no therapy supported the NNUTI diagnosis. Results. In 5 months, 29226 urine samples were evaluated. 401 patients were reported as NNUTI. Of these, only 5 (1.2%) patients met criteria for potential symptomatic UTI. Two patients treated for asymptomatic UTI were subsequently diagnosed with Clostridium difficile infection and renal failure, respectively. The second patient died of an adverse reaction to antibiotic therapy. No patient was adversely impacted by a NNUTI culture report. Conclusion. The new reporting criteria accurately reported the absence of a UTI in >98% of samples that had bacterial counts of <10 CFU/ml. Overtreatment of UTI has serious clinical consequences. Disclosures. All authors: No reported disclosures.

637Control of Methicillin-Resistant Staphylococcus aureus (MRSA) in Long Term Care is Possible While Maintaining Patient Socialization without Isolation

637. Control of Methicillin-Resistant Staphylococcus aureus (MRSA) in Long Term Care is Possible While Maintaining Patient Socialization without Isolation Becky Smith, MD; Susan Boehm, RN, BSN; Jennifer Beaumont, MS; Ari Robicsek, MD; Parul Patel, BS MT(ASCP), CCRP; Donna Schora, MT(ASCP); Deborah Burdsall, RN-BC, CIC; Kari Peterson, BA; Maureen Fausone, BA; Lance Peterson, MD; Infectious Diseases, Pritzker School of Medicine, University of Chicago, Chicago, IL; NorthShore University HealthSystem, Evanston, IL; Department of Medical Social Sciences, Northwestern University, Chicago, IL; Infection Control, Lutheran Home/Lutheran Life Communities, Arlington Heights, IL; Research, NorthShore University HealthSystem, Evanston, IL; Pritzker School of Medicine, University of Chicago, Chicago, IL

Multidrug-resistant organisms contaminating supply carts of contact isolation patients

Contamination of supply carts stored within rooms of patients on contact isolation for multidrug-resistant organisms was assessed. Despite the presence of environmentally persistent organisms, very little contamination occurred to these carts or the supplies stored within them. A single isolate containing a multidrug-resistant Acinetobacter baumannii was isolated, representing 1.3% of the 80 swabs collected.