Daniel Shirley

Effects of smoking on non-AIDS-related morbidity in HIV-infected patients.

Tobacco smoking has many adverse health consequences. Patients with human immunodeficiency virus (HIV) infection smoke at very high rates, and many of the comorbidities associated with smoking in the general population are more prevalent in this population. It is likely that a combination of higher smoking rates along with an altered response to cigarette smoke throughout the body in persons with HIV infection leads to increased rates of the known conditions related to smoking. Several AIDS-defining conditions associated with smoking have been reviewed elsewhere. This review aims to summarize the data on non-AIDS-related health consequences of smoking in the HIV-infected population and explore evidence for the potential compounding effects on chronic systemic inflammation due to HIV infection and smoking.

Screening for Chronic Obstructive Pulmonary Disease (COPD) in an Urban HIV Clinic: A Pilot Study.

Increased smoking and a detrimental response to tobacco smoke in the lungs of HIV/AIDS patients result in an increased risk for COPD. We aimed to determine the predictive value of a COPD screening strategy validated in the general population and to identify HIV-related factors associated with decreased lung function. Subjects at least 35 years of age at an HIV clinic in New York City completed a COPD screening questionnaire and peak flow measurement. Those with abnormal results and a random one-third of normal screens had spirometry. 235 individuals were included and 89 completed spirometry. Eleven (12%) had undiagnosed airway obstruction and 5 had COPD. A combination of a positive questionnaire and abnormal peak flow yielded a sensitivity of 20% (specificity 93%) for detection of COPD. Peak flow alone had a sensitivity of 80% (specificity 80%). Abnormal peak flow was associated with an AIDS diagnosis (p=0.04), lower nadir (p=0.001), and current CD4 counts (p=0.001). Nadir CD4 remained associated in multivariate analysis (p=0.05). Decreased FEV1 (<80% predicted) was associated with lower CD4 count nadir (p=0.04) and detectable current HIV viral load (p=0.01) in multivariate analysis. Questionnaire and peak flow together had low sensitivity, but abnormal peak flow shows potential as a screening tool for COPD in HIV/AIDS. These data suggest that lung function may be influenced by HIV-related factors.

Prevalence, risk factors, and outcomes of idle intravenous catheters: An integrative review

OBJECTIVE Complications of intravenous catheters remain a major contributor to health care costs and are a patient safety problem. An intravenous catheter not actively in use-an idle catheter-may increase the risk of infectious and noninfectious complications. We conducted an integrative review of the available literature to evaluate the prevalence, risk factors, and outcomes associated with idle intravenous catheters. METHODS Searches of multiple computerized databases were conducted to identify studies on idle intravenous catheters. Data on definitions of idle catheter, type of catheter, prevalence, risk factors, and patient outcomes were extracted. RESULTS Thirteen studies met inclusion criteria and were included in the review. The location and setting of the studies were diverse, including cross-sectional, retrospective, and prospective, and were conducted in varied geographic locations. The definition of an idle catheter was variable across studies. Although studies varied in terms of line-days or number of catheters placed, the primary definition of idle device was based on number of days or percent of devices left in situ without use. Four studies evaluated patient outcomes associated with idle catheters and found increased risk of infection, intensive care unit admission, and phlebitis. CONCLUSIONS Idle intravenous catheters are common and are associated with adverse outcomes. Prospective studies incorporating uniform definitions of idle catheters to test interventions to reduce idle catheter use are urgently needed.

Challenges to Safe Injection Practices in Ambulatory Care.

Most recent infection outbreaks caused by unsafe injection practices in the United States have occurred in ambulatory settings. We utilized direct observation and a survey to assess injection practices at 31 clinics. Improper vial use was observed at 13 clinics (41.9%). Pharmacy support and healthcare worker education may improve injection practices. Infect Control Hosp Epidemiol 2017;38:614-616.

Incorporation of Leadership Rounds in CAUTI Prevention Efforts

Leadership engagement is an important aspect of integrating best practices at the bedside. The catheter-associated urinary tract infection (CAUTI) prevention workgroup at our academic medical center implemented leadership rounding in partnership with clinical staff to increase participation in CAUTI prevention initiatives on inpatient units. There was an associated decrease in urinary catheter utilization and CAUTI rates. Implementation of leadership rounds should be considered as a part of comprehensive CAUTI prevention efforts in health care settings.

Tobacco use as a screener for Clostridium difficile infection outcomes

A retrospective cohort study was conducted to evaluate the utility of self-reported tobacco use for developing a clinical prediction rule for poor outcomes of Clostridium difficile infection. Patients with any history of smoking were significantly less likely than never smokers to be cured of their infection within two weeks. Disease recurrence, readmission within 30 days, death before treatment completion, and the severity of Clostridium difficile infection were not associated with smoking status.

Barriers and Facilitators to Injection Safety in Ambulatory Care Settings

OBJECTIVEIdentify factors referred to as barriers and facilitators that can prevent or assist safe injection practices in ambulatory care settings to guide quality improvement.DESIGNIn this mixed-methods study, we utilized observations and interviews.SETTINGThis study was conducted at ambulatory clinics at a midwestern academic medical center from May through August 2017. Sites included a variety of clinical settings that performed intramuscular, intradermal, intravenous, or intra-articular injections.PARTICIPANTS AND INTERVENTIONSDirect observations of injections and interviews of ambulatory care staff were conducted. An observation checklist was created, including standards of injection safety from nationally recognized guidelines. Interview questions were developed using the System Engineering Initiative for Patient Safety (SEIPS) model. Interviews were recorded, transcribed, and then coded by 2 investigators.RESULTSIn total, 106 observations and 36 interviews were completed at 21 clinics. Injection safety standards with the lowest adherence included using needleless access devices to prepare injections (33%) and the proper use of multidose vials (<80%). Of 819 coded interview segments, 461 (56.3%) were considered facilitators of safe injection practices. The most commonly identified barriers were patient movement during administration, feeling rushed, and inadequate staffing. The most commonly identified facilitators were availability of supplies, experience in the practice area, and availability of safety needles and prefilled syringes.CONCLUSIONSPerceived barriers and facilitators to infection control elements of injection safety are interconnected with SEIPS elements of persons, organizations, technologies, tasks, and environment. Direct observations demonstrated that knowledge of safety injection standards does not necessarily translate to best practices and may not match self-reported data.Infect Control Hosp Epidemiol 2018;39:841-848.

Outcomes of Community and Healthcare Onset Clostridium difficile Infection

BACKGROUND Community-onset Clostridium difficile infections (CDI) are increasingly common, but there is little data on outcomes. The purpose of this study is to describe the epidemiology and outcomes of CDI in the Veterans Health Administration (VHA) system and compare these variables between hospital-onset (HCF) and community-onset (CO) cases. METHODS We conducted a retrospective cohort study that included all patients with a positive test for C. difficile (toxin or toxin genes) within the VHA Corporate Data Warehouse between 2011 and 2014. RESULTS We identified 19270 episodes of CDI, involving 15972 unique patients; 95% were male, 44% of the cases were HCF, and 42% were CO. Regarding severity, 31% percent of cases were non-severe, 40% were severe, and 21% were fulminant. Exposure to proton pump inhibitors was found in 53% of cases (47% in CO, 62% in HCF). Overall, 40% of patients received antibiotics in the 90 days before CDI (44% in HCF, 36% in CO). Recurrence was 18.2%, and 30-day all-cause mortality was 9.2%. Risk factors for a fulminant case were exposure to clindamycin (odds ratio [OR]: 1.23, P = .01) or proton pump inhibitors (OR: 1.20, P < .001) in the 90 days prior to diagnosis. CONCLUSIONS CO accounts for a significant proportion of CDI in the VHA system. CO patients are younger and their cases are less severe, but recurrence is more common than in HCF CDI. Therefore CO CDI may account for a considerable reservoir of CDI cases, and prevention efforts should include interventions to reduce CO CDI.

Wisconsin microbiome study, a cross-sectional investigation of dietary fibre, microbiome composition and antibiotic-resistant organisms: rationale and methods

Introduction Prevention of multidrug-resistant organism (MDRO) infections, such as those caused by methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, fluoroquinolone-resistant Gram-negative bacteria and Clostridium difficile is crucial. Evidence suggests that dietary fibre increases gut microbial diversity, which may help prevent colonisation and subsequent infection by MDROs. The aim of the Winning the War on Antibiotic Resistance (WARRIOR) project is to examine associations of dietary fibre consumption with the composition of the gut microbiota and gut colonisation by MDROs. The secondary purpose of the study is to create a biorepository of multiple body site specimens for future microbiota research. Methods and analysis The WARRIOR project collects biological specimens, including nasal, oral and skin swabs and saliva and stool samples, along with extensive data on diet and MDRO risk factors, as an ancillary study of the Survey of the Health of Wisconsin (SHOW). The SHOW is a population-based health survey collecting data on several different health determinants and outcomes, as well as objective body measurements and biological specimens. WARRIOR participants include 600 randomly selected Wisconsin residents age 18 and over. Specimens are screened for MDRO colonisation and DNA is extracted for 16S ribosomal RNA-based microbiota sequencing. Data will be analysed to assess the relationship between dietary fibre, the gut microbiota composition and gut MDRO colonisation. Ethics and dissemination The WARRIOR project is approved by the University of Wisconsin Institutional Review Board. The main results of this study will be published in a peer-reviewed scientific journal.

Cessation-related information, motivation, and behavioral skills in smokers living with HIV

ABSTRACT There is a need for new, targeted smoking cessation interventions for smokers living with HIV. The Information-Motivation-Behavioral Skills (IMB) model has been applied effectively to HIV-related health behaviors and was used in this qualitative study to elicit factors that could lead to the development of innovative and successful cessation interventions for this population. Twenty individuals who smoked from two clinics providing care to people living with HIV participated in open-ended interviews, responding to questions covering the domains of the IMB model, as applied to smokers living with HIV. Participants were enrolled from a larger survey cohort to recruit into groups based on the impact of HIV diagnosis on smoking as well as attempting to enroll a mix of demographics characteristics. Interviews were recorded, transcribed, coded and thematically analyzed using a grounded theory qualitative approach. Interviews continued until thematic saturation was reached. Major themes included: Presence of knowledge deficits regarding HIV-specific health risks of smoking; use of smoking for emotional regulation, where many reported close contacts who smoke and concern with the effect of cessation on their social networks; Use of smoking cessation aids or a telephone-based wellness intervention were acceptable to most. Providing HIV-specific information in cessation advice is of the utmost importance for clinicians caring for smokers living with HIV, as this theme was noted consistently as a potential motivator to quit. Innovative and effective interventions must account for the social aspect of smoking and address other methods of emotional regulation in this population.