Christopher Kovacs

A Multifaceted Approach to Reduction of Catheter-Associated Urinary Tract Infections in the Intensive Care Unit With an Emphasis on “Stewardship of Culturing”

BACKGROUND Catheter-associated urinary tract infections (CAUTIs) are among the most common hospital-acquired infections (HAIs). Reducing CAUTI rates has become a major focus of attention due to increasing public health concerns and reimbursement implications. OBJECTIVE To implement and describe a multifaceted intervention to decrease CAUTIs in our ICUs with an emphasis on indications for obtaining a urine culture. METHODS A project team composed of all critical care disciplines was assembled to address an institutional goal of decreasing CAUTIs. Interventions implemented between year 1 and year 2 included protocols recommended by the Centers for Disease Control and Prevention for placement, maintenance, and removal of catheters. Leaders from all critical care disciplines agreed to align routine culturing practice with American College of Critical Care Medicine (ACCCM) and Infectious Disease Society of America (IDSA) guidelines for evaluating a fever in a critically ill patient. Surveillance data for CAUTI and hospital-acquired bloodstream infection (HABSI) were recorded prospectively according to National Healthcare Safety Network (NHSN) protocols. Device utilization ratios (DURs), rates of CAUTI, HABSI, and urine cultures were calculated and compared. RESULTS The CAUTI rate decreased from 3.0 per 1,000 catheter days in 2013 to 1.9 in 2014. The DUR was 0.7 in 2013 and 0.68 in 2014. The HABSI rates per 1,000 patient days decreased from 2.8 in 2013 to 2.4 in 2014. CONCLUSIONS Effectively reducing ICU CAUTI rates requires a multifaceted and collaborative approach; stewardship of culturing was a key and safe component of our successful reduction efforts. Infect Control Hosp Epidemiol 2017;38:186-188.

Selecting suitable solid organ transplant donors: Reducing the risk of donor-transmitted infections.

Selection of the appropriate donor is essential to a successful allograft recipient outcome for solid organ transplantation. Multiple infectious diseases have been transmitted from the donor to the recipient via transplantation. Donor-transmitted infections cause increased morbidity and mortality to the recipient. In recent years, a series of high-profile transmissions of infections have occurred in organ recipients prompting increased attention on the process of improving the selection of an appropriate donor that balances the shortage of needed allografts with an approach that mitigates the risk of donor-transmitted infection to the recipient. Important advances focused on improving donor screening diagnostics, using previously excluded high-risk donors, and individualizing the selection of allografts to recipients based on their prior infection history are serving to increase the donor pool and improve outcomes after transplant. This article serves to review the relevant literature surrounding this topic and to provide a suggested approach to the selection of an appropriate solid organ transplant donor.

Impact of pretransplant rifaximin therapy on early post–liver transplant infections

Bacterial and fungal infections are major causes of morbidity and mortality after liver transplantation (LT). The role of intestinal decontamination in the prevention of post‐LT infections is controversial. Rifaximin is widely used for the treatment of hepatic encephalopathy. The effect of rifaximin on post‐LT infections is unknown. The aim of our study was to determine the effect of rifaximin therapy in the pretransplant period on early bacterial infections (EBIs) and fungal infections within the first 30 days after LT. All adult patients who underwent LT at our institution (January 2009 to July 2011) were included in this retrospective cohort study. Patients receiving antibiotics other than pretransplant protocol antibiotics were excluded. Patients were stratified into 2 groups based on the presence or absence of rifaximin therapy for at least 2 days before LT. Infections were defined by the isolation of any bacterial or fungal organisms within 30 days of LT. Multivariate regression analysis, Student t tests, and Pearsons chi‐square tests were used to compare the 2 groups. Two hundred sixty‐eight patients were included, and 71 of these patients (26.5%) were on rifaximin at the time of LT. The 2 groups were comparable with respect to age, sex, race, and Model for End‐Stage Liver Disease score. There were no significant differences in the rates of EBIs (30% for the non‐rifaximin group and 25% for the rifaximin group, P = 0.48) or fungal infections between the 2 groups. There was no increase in antimicrobial resistance among the infecting organisms. There was no difference in survival between the rifaximin and non‐rifaximin groups (98% versus 97%, P = 0.36). In conclusion, the use of rifaximin in the pre‐LT period was not associated with an increased risk of bacterial or fungal infections in the early post‐LT period. Liver Transpl 20:544–551, 2014.

Delayed diagnosis of Q fever endocarditis in a rheumatoid arthritis patient

Chronic Q fever caused by Coxiella burnetii is uncommon in the United States and is most often associated with infective endocarditis. We present a 52-year-old woman with a history of aortic valve replacement and rheumatoid arthritis treated with Etanercept with chronic Q fever manifesting as prosthetic valve infective endocarditis. Explanted valve tissue showed organisms confirmed to be C. burnetii by PCR (polymerase chain reaction) sequencing. She subsequently reported consumption of unpasteurized cow milk which was the likely source of C. burnetii. She continues to do well 6 months after valve replacement on oral doxycycline and hydroxychloroquine.

Hospital-acquired Staphylococcus aureus primary bloodstream infection: A comparison of events that do and do not meet the central line–associated bloodstream infection definition

BACKGROUND This study was done to describe the incidence and outcomes of primary hospital-acquired bloodstream infection (HABSI) secondary to Staphylococcus aureus (SA) that did and did not meet the National Healthcare Safety Networks (NHSNs) definition for central line-associated bloodstream infection (CLABSI). METHODS Consecutive hospitalized patients during a 48-month study period with an SA HABSI were categorized according to those who did and did not meet the NHSNs definitions for CLABSI and non-CLABSI. Primary outcomes were mortality at 30 days and 1 year. Secondary outcomes were the incidence of complicated bacteremia and the need for operative intervention secondary to the HABSI event. RESULTS A total of 122 episodes of primary SA HABSIs were identified: 78 (64%) were CLABSIs, and 44 (36%) were non-CLABSIs. Overall 30-day and 1-year mortality in the cohort was 21.3% and 38.5%, respectively, and did not differ significantly between the 2 groups. Complicated SA HABSI was significantly more common in the non-CLABSI group (15.9% [n = 7] vs 0% [n = 0], P ≤ .001). CONCLUSIONS Primary SA HABSI was associated with significant 30-day and 1-year mortality. Complications from SA non-CLABSI requiring surgical intervention were significantly more common than in those with a CLABSI event. Our findings affirm the significance of non-device-related hospital-acquired infections.

Infectious diseases consult improves vaccination adherence in kidney transplant candidates

BACKGROUND Vaccines prevent infections and avoid related complications. Low rates in immunocompromised patients are concerning due to increased morbidity. Vaccinations are less effective when administered post-transplant and should be administered prior. We describe pre-transplant vaccination rates among kidney or kidney-pancreas transplant recipients. METHODS Retrospective review including adults receiving kidney or kidney-pancreas allografts at Cleveland Clinic from October 2013 to October 2016. Pre-transplant vaccinations, serologies, and transplant data were collected. RESULTS 393 patients were included; median age was 53 years with most (46%) being Caucasian males. Influenza vaccination rate was 48%; receipt of at least one pneumococcal vaccine was 77%. Vaccination rates were higher among dialysis patients for pneumococcal, hepatitis B, and varicella vaccines; rates were also higher with infectious diseases consults. CONCLUSIONS Vaccination rates at our institution for kidney or kidney-pancreas transplant candidates are consistent with previous literature. Rates were higher for candidates with infectious diseases consults or receiving dialysis.

856Hospital Acquired Staphylococcus aureus Primary Blood Stream Infection: A Comparison of Events That Do and Do Not Meet Central Line Associated Bloodstream Infection (CLABSI) Definition

Background. Hospital acquired bloodstream infection (HABSI) due to Staphylococcus aureus (SA) causes infectious complications in hospitalized patients. We assessed the outcomes of primary SA HABSIs that meet and do not meet the NHSN CLABSI definition. Methods. Cases of primary SA HABSI were identified using an infection prevention surveillance database from January 1, 2010 to December 31, 2013 and categorized as being CLABSI or non-CLABSI (nCLABSI) according to NHSN definitions. The electronic medical record was reviewed to obtain clinical variables. Complicated bacteremia was defined as the presence of: septic thrombophlebitis, cardiac device infections, vertebral osteomyelitis, or infective endocarditis. Primary outcomes were mortality at 30 days and 1 year, septic thrombophlebitis, cardiac device infection, vertebral osteomyelitis, infective endocarditis, and complicated bacteremia. Results. CLABSI and nCLABSI infections numbered 78 and 44, respectively, and are described in the table. 26 nCLABSI infections were associated with a peripheral IV (16) or a midline catheter (10). Mean time from admission to first positive culture was shorter for nCLABSI infections (6 vs 16.3 days; p = <0.001). The Charlson Comorbidity Indices, rate of ID consultation, 30 day and 1 year mortality were not different between the groups.