Jennifer L. Beaumont

Universal Surveillance for Methicillin-Resistant Staphylococcus aureus in 3 Affiliated Hospitals

Context Efforts to reduce the frequency of methicillin-resistant Staphylococcus aureus (MRSA) infections have failed until now. Contribution After a baseline year, the authors screened all intensive care unit admissions for MRSA colonization using polymerase chain reaction. In year 3, they screened all hospital admissions. They placed patients who tested positive for MRSA on contact precautions. The prevalence density of MRSA clinical infection was 8.9, 7.4, and 3.9 per 10000 patient-days in years 1, 2, and 3, respectively. Methicillin-sensitive S. aureus infection rates did not change. Caution There was no concomitant, unscreened control group. Implication Screening for MRSA colonization is associated with substantially reduced rates of MRSA clinical infection. The Editors Methicillin-resistant Staphylococcus aureus (MRSA) is now endemic in many U.S. hospitals (1, 2). Colonization with this organism is a risk factor for eventual MRSA clinical infection (3), which is associated with high cost (4) and poor clinical outcomes (5). The burden of health careassociated MRSA disease is high and may be increasing: In their multiregion survey of invasive MRSA disease, investigators for the Centers for Disease Control and Prevention noted substantial increases in both community- and health careassociated infections at several sites when comparing data from 2001 to 2002 with data from 2004 to 2005 (6). Driven by the emerging concern that community-associated MRSA has entered the hospital environment (7), the medical community and the public are seeking to limit the spread of this organism with increasing urgency (8). In the United Kingdom, the Department of Health has instituted mandatory reporting of MRSA infections in hospitals (9), and in the United States, state legislatures are considering (or have passed bills) requiring active surveillance for MRSA (1012). Consumer organizations (13) and the media (14) also seek action. The Healthcare Infection Control Practices Advisory Committee of the Centers for Disease Control and Prevention (15) recently published guidelines recommending expanded surveillance of asymptomatic patients in settings in which multidrug-resistant organisms are poorly controlled with other measures. However, the evidence supporting this practice is limited to surveillance on circumscribed (for example, intensive care only) populations in small, single-center studies at large academic hospitals (1618). Because rates of MRSA infection remained unacceptably high despite conventional interventions, we implemented expanded surveillance at our 3-hospital health care organization in 2 steps. For 12 months, we implemented organization-wide, intensive care unit (ICU)based MRSA surveillance. On 1 August 2005, we initiated the first program (to our knowledge) of universal surveillance of all hospital admissions in the United States. We aimed to determine whether expanded surveillance was associated with changes in the rate of MRSA clinical disease. Methods We measured the utility of expanded surveillance for MRSA by using a 3-period before-and-after design (Figure 1). Period 1 (no active surveillance) was the baseline. In periods 2 and 3, we introduced ICU-based surveillance and universal admission surveillance, respectively. We compared MRSA disease rates during and after hospitalization in the 3 periods. Figure 1. Intervention timeline. ICU = intensive care unit; MRSA = methicillin-resistant Staphylococcus aureus. Outcomes The primary outcome was aggregate hospital-associated MRSA infection rate, defined as the sum of all MRSA bloodstream, respiratory, urinary tract, and surgical site clinical infections occurring more than 48 hours after admission through day 30 after discharge. Secondary outcomes were rates of health careassociated MRSA and methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia, rates of aggregate MRSA infections occurring up to 180 days after discharge, and adherence to MRSA surveillance. We defined adherence as the percentage of admissions (ICU or whole house, depending on the period) in which surveillance testing was done. Study Sites Evanston Northwestern Healthcare, Evanston, Illinois, is a 3-hospital organization with approximately 40000 annual admissions, 75 affiliated off-site offices, 450 staff physicians, and more than 1000 affiliated physicians. Hospital 1 is an academic facility with several residency programs, 476 beds, and a high proportion of surgical patients. Hospital 2 is a primary care teaching hospital with 143 beds that serves a large population of long-term care facility residents (the elderly) relative to the other 2 hospitals. Hospital 3 is a community hospital with 239 beds. The total number of ICU beds was 45 (5.2% of all beds). Surveillance, Isolation, and Decolonization During the baseline year (period 1), routine surveillance for MRSA colonization did not occur. Patients who were MRSA-colonized on the basis of clinical cultures were placed in contact isolation, and decolonization was not attempted. During all periods, contact isolation consisted of a private room or a shared room with another MRSA-colonized patient. Gowns and gloves were required for all room entries, and patient rooms were supplied with dedicated equipment (for example, stethoscopes) for staff use. During period 2, a policy of nasal surveillance for MRSA colonization was enforced for all ICU admissions. Test turnaround time was 2.5 days. Colonized patients were isolated; decolonization therapy was not standard policy. During period 3, a policy of nasal surveillance for MRSA colonization was enforced for all hospitalizations on entry into a ward room (that is, day 1 of admission). A nurse or patient care technician obtained the specimen. Average test turnaround time was 0.67 day. Nursing staff were notified of results by telephone. Adherence was promoted through in-service education for all nursing staff and educational rounds for physicians (19). During this period, we monitored adherence and provided feedback in real time to underperforming nursing units. The infection control department recommended treatment of colonized patients with a 5-day regimen comprising mupirocin calcium, 2% twice daily to the nares, and a chlorhexidine 4% wash or shower every 2 days during period 3. Patients who were discharged before therapy was complete were sent home with prescriptions to complete this regimen. Because we felt that the decision to decolonize should be at the discretion of the physician, we did not monitor adherence to decolonization, nor did we define it as an outcome of the study. However, we had access to pharmacy data for most patients who tested positive for MRSA during the first 12 months of period 3, and we used it to determine adherence to at least 1 chlorhexidine wash and 4 or more doses of mupirocin (a quantity that seems as effective as 10 doses [20]). Patients were not removed from isolation after decolonization therapy unless another test (done at least 7 days after decolonization therapy during the same hospitalization or on repeated hospitalization) was negative for MRSA. Laboratory Methods Polymerase chain reaction tests for S. aureus colonization have better sensitivity than culture-based assays, but they may yield more false-positive results (21). Real-time polymerase chain reaction was used for MRSA detection in periods 2 (22) and 3 (21). Our in-house method and the commercial assay (BD-GeneOhm real-time polymerase chain reaction test, Becton Dickinson, Franklin Lakes, New Jersey) have equal sensitivity (21, 22). For the commercial assay, we modified the package insert protocol for specimen processing to facilitate high-volume testing (21). Data Collection Demographic Characteristics Administrative data were used to determine admission, procedure, and demographic data for all patients hospitalized from 1 August 2003 to 30 April 2007. We used International Classification of Diseases, Ninth Revision, diagnostic and procedure codes to generate comorbidity data according to the method of Elixhauser and coworkers (23) with Healthcare Cost and Utilization Project comorbidity software, version 3.2 (Agency for Healthcare Research and Quality, Rockville, Maryland) (24). Infections To measure the effect of our intervention, we were interested in true clinical disease due to MRSA. Therefore, we reviewed the records of all patients with positive inpatient or outpatient clinical cultures for MRSA from 1 August 2003 to 30 April 2007. Infections were determined as follows: bacteremia = any positive blood culture; bloodstream infection = positive blood culture in the absence of a positive clinical culture from another site; respiratory tract infection = positive respiratory culture, compatible chest radiograph, and decision to treat; urinary tract infection = positive urine culture and either a decision to treat or growth of more than 100000 colony-forming units/mL plus at least 50 leukocytes per high-power field; and surgical site infection = positive culture of a surgical site. These infection types, although not encompassing all MRSA infections at our organization, represent the major body sites affected by culture-demonstrable MRSA disease. Our primary outcome measure was the rate of clinical hospital-associated MRSA infections. Infections occurring more than 2 days after the admission date and within 30 days after discharge were considered hospital-associated. Rates of hospital-associated MRSA and hospital-associated MSSA were expressed as prevalence density of infections, that is, the number of infections per 10000 inpatient-days. Patients were counted once every 30-day period. In a separate analysis of the timing of MRSA infections, disease prevalence (that is, infections per 10000 admissions) was measured during admission and in 6 postdischarge, 30-day time frames. Statistical Analysis Rates of MRSA Infection For 1 hospital-associated infection analysis, we compared infection

Long-Term Health-Related Quality of Life, Growth, and Spiritual Well-Being After Hematopoietic Stem-Cell Transplantation

PURPOSE To examine health-related quality of life (HRQOL) and growth, and spiritual well-being in adult survivors of hematopoietic stem-cell transplantation (HSCT) for a malignant disease. METHODS HSCT survivors (n = 662) were recruited through the International Bone Marrow Transplant Registry/Autologous Blood and Marrow Transplant Registry and were drawn from 40 transplantation centers. HSCT survivors completed a telephone interview and a set of questionnaires a mean of 7.0 years post-HSCT (range, 1.8 to 22.6 years). Study measures included a variety of standardized measures of HRQOL and growth and spiritual well-being. An age- and sex-matched healthy comparison (HC) group (n = 158) was recruited using a peer nomination method. The HC group completed a parallel telephone interview and set of questionnaires. RESULTS Multivariate analysis of variance analyses found the HSCT survivor group reported poorer status relative to the HC group for all HRQOL outcome clusters including physical health, physical functioning, social functioning, psychological adjustment, and dyadic adjustment. In contrast, the HSCT survivor group reported more psychological and interpersonal growth. Mean effect size for the 24 outcome indices examined was 0.36 standard deviations, an effect size often considered clinically meaningful or important. The largest group differences were found for measures of general health, physical function and well-being, depression, cognitive function, and fatigue. CONCLUSION The experience of HSCT for a malignant disease has a wide-ranging, longstanding, and profound impact on adult recipients. Relative to healthy controls, HSCT survivors reported poorer physical, psychological, and social functioning but, conversely, more psychological and interpersonal growth, differences that appeared to persist many years after HSCT.

Cognition assessment using the NIH Toolbox

Vision is a sensation that is created from complex processes and provides us with a representation of the world around us. There are many important aspects of vision, but visual acuity was judged to be the most appropriate vision assessment for the NIH Toolbox for Assessment of Neurological and Behavioral Function, both because of its central role in visual health and because acuity testing is common and relatively inexpensive to implement broadly. The impact of visual impairments on health-related quality of life also was viewed as important to assess, in order to gain a broad view of ones visual function. To test visual acuity, an easy-to-use software program was developed, based on the protocol used by the E-ETDRS. Children younger than 7 years were administered a version with only the letters H, O, T, and V. Reliability and validity of the Toolbox visual acuity test were very good. A 53-item vision-targeted, health-related quality of life survey was also developed.

Late effects of cancer and hematopoietic stem-cell transplantation on spouses or partners compared with survivors and survivor-matched controls

PURPOSE Little is known about the long-term effects of cancer and hematopoietic stem-cell transplantation (HCT) on spouses or partners. The purpose of this study was to examine the health-related quality of life and post-traumatic growth (PTG) of spouses/partners compared with survivors and controls and to identify factors associated with those outcomes. PATIENTS AND METHODS HCT survivor/partner pairs (n = 177), coupled continuously since HCT, were drawn from 40 North American transplantation centers. Married peer-nominated acquaintances (of survivors) served as controls (n = 133). Outcomes were measured a mean of 6.7 years after HCT (range, 1.9 to 19.4 years). RESULTS As expected, self-reported partner physical health was similar to controls and better than survivors (P < .001). However, partners reported more fatigue and cognitive dysfunction than controls (P < .001 for both), although less than survivors. Partners and survivors reported more depressive symptoms and sleep and sexual problems than controls (P < .001, P < .01, and P < .01, respectively). Odds of partner depression were nearly 3.5 times that of controls (P < .002). Depressed partners were less likely than depressed survivors to receive mental health treatment (P < .04). Partners reported less social support (P < .001), dyadic satisfaction (P < .05), and spiritual well-being (P < .05) and more loneliness (P < .05) than both survivors and controls. In contrast to survivors, partners reported little PTG (P < .001). Factors associated with partner outcomes included partner health problems, coping, female sex, social constraint, survivor depression, optimism, multiple life changes, and social support. CONCLUSION Spouses/partners experience similar emotional and greater social long-term costs of cancer and HCT than survivors without the potential compensatory benefits of PTG. Some of the factors associated with partner outcomes are amenable to intervention.

II. NIH Toolbox Cognition Battery (CB): measuring executive function and attention.

In this chapter, we discuss two measures designed to assess executive function (EF) as part of the NIH Toolbox Cognition Battery (CB) and report pediatric data from the validation study. EF refers to the goal-directed cognitive control of thought, action, and emotion. Two measures were adapted for standardized computer administration: the Dimensional Change Card Sort (a measure of cognitive flexibility) and a flanker task (a measure of inhibitory control in the context of selective visual attention). Results reveal excellent developmental sensitivity across childhood, excellent reliability, and (in most cases) excellent convergent validity. Correlations between the new NIH Toolbox measures and age were higher for younger children (3-6 years) than for older children (8-15 years), and evidence of increasing differentiation of EF from other aspects of cognition (indexed by receptive vocabulary) was obtained.

Duration of Colonization with Methicillin-Resistant Staphylococcus aureus

The duration of colonization with methicillin-resistant Staphylococcus aureus is not well defined. During 1564 admissions after a clinical culture or surveillance test positive for methicillin-resistant Staphylococcus aureus, we retested patients for methicillin-resistant Staphylococcus aureus colonization. During the first year after the positive culture result was obtained, 48.8% of the patients (95% confidence interval, 45.8%-51.7%) remained colonized; at 4 years, 21.2% of the patients (95% confidence interval, 13.1%-31.4%) remained colonized.

Familial risk for common diseases in primary care: the Family Healthware Impact Trial.

CONTEXT Family history is a risk factor for many common chronic diseases, yet it remains underutilized in primary care practice. BACKGROUND Family Healthware is a self-administered, web-based tool that assesses familial risk for CHD; stroke; diabetes; and colorectal, breast, and ovarian cancer, and provides a personalized prevention plan based on familial risk. The Family Healthware Impact Trial evaluated the tool. DESIGN In this cluster RCT, participants completed baseline and 6-month follow-up surveys. The intervention group used Family Healthware directly after the baseline survey. Controls used the tool after completing the follow-up survey. SETTING/PARTICIPANTS Patients aged 35-65 years with no known diagnosis of these six diseases were enrolled from 41 primary care practices. MAIN OUTCOME MEASURES The prevalence of family-history-based risk for coronary heart disease (CHD); stroke; diabetes; and colorectal, breast, and ovarian cancer was determined in a primary care population. RESULTS From 2005 to 2007, 3786 participants enrolled. Data analysis was undertaken from September 2007 to March 2008. Participants had a mean age of 50.6 years and were primarily white (91%) women (70%). Of the 3585 participants who completed the risk assessment tool, 82% had a strong or moderate familial risk for at least one of the diseases: CHD (strong=33%, moderate=26%); stroke (strong=15%, moderate=34%); diabetes (strong=11%, moderate=26%); colorectal cancer (strong=3%, moderate=11%); breast cancer (strong=10%, moderate=12%); and ovarian cancer (strong=4%, moderate=6%). Women had a significantly (p<0.04) higher familial risk than men for all diseases except colorectal and ovarian cancer. Overweight participants were significantly (p<or=0.02) more likely to have a strong family history for CHD, stroke, and diabetes. Older participants were significantly (p<or=0.02) more likely to report a strong family history for CHD and stroke as well as colorectal and breast cancer. CONCLUSIONS This self-administered, online tool delineated a substantial burden of family-history-based risk for these chronic diseases in an adult, primary care population. TRIAL REGISTRATION NCT00164658.

Topical Therapy for Methicillin-Resistant Staphylococcus aureus Colonization Impact on Infection Risk

OBJECTIVE We evaluated the usefulness of topical decolonization therapy for reducing the risk of methicillin-resistant Staphylococcus aureus (MRSA) infection among MRSA-colonized inpatients. DESIGN Retrospective cohort study. SETTING AND INTERVENTION Three hospitals with universal surveillance for MRSA; at their physicians discretion, colonized patients could be treated with a 5-day course of nasal mupirocin calcium 2%, twice daily, plus chlorhexidine gluconate 4% every second day. PATIENTS AND METHODS MRSA carriers were later retested for colonization (407 subjects; study 1) or followed up for development of MRSA infection (933 subjects; study 2). Multivariable methods were used to determine the impact of decolonization therapy on the risks of sustained colonization (in study 1) and MRSA infection (in study 2). RESULTS Independent risk factors for sustained colonization included residence in a long-term care facility (odds ratio [OR], 1.8 [95% confidence interval [CI], 1.1-3.2]) and a pressure ulcer (OR, 2.3 [95% CI, 1.2-4.4]). Mupirocin at any dose decreased this risk, particularly during the 30-60-day period after therapy; mupirocin resistance increased this risk (OR, 4.1 [95% CI, 1.6-10.7]). Over a median follow-up duration of 269 days, 69 (7.4%) of 933 patients developed infection. Independent risk factors for infection were length of stay (hazard ratio [HR], 1.2 per 5 additional days [95% CI, 1.0-1.4]), chronic lung disease (HR, 1.7 [95% CI, 1.0-2.8]), and receipt of non-MRSA-active systemic antimicrobial agents (HR, 1.8 [95% CI, 1.1-3.1]). Receipt of mupirocin did not affect the risk of infection, although there was a trend toward delayed infection among patients receiving mupirocin (median time to infection, 50 vs 15.5 days; P=.06). CONCLUSIONS Mupirocin-based decolonization therapy temporarily reduced the risk of continued colonization but did not decrease the risk of subsequent infection.

Mucositis-Related Morbidity and Resource Utilization in Head and Neck Cancer Patients Receiving Radiation Therapy With or Without Chemotherapy

The objective of this study was to estimate health care-resource utilization in head and neck cancer (HNC) patients. This was a prospective, longitudinal, multicenter, noninterventional study of mucositis in patients receiving radiation with or without chemotherapy for HNC. Mouth and throat soreness and functional impairment were measured using the Oral Mucositis Weekly Questionnaire-HNC. Resource utilization data were obtained from patient interviews and recorded from the patients medical chart. Seventy-five patients were enrolled from six centers. Fifty (67%) patients received concurrent chemoradiation therapy; 34 (45%) received intensity-modulated radiation therapy. Over the course of treatment, 57 (76%) patients reported severe mouth and throat soreness. Pain and functional impairment because of mouth and throat soreness increased during the course of therapy despite the use of opioid analgesics in 64 (85%) of the patients. Complications of radiation therapy resulted in increased patient visits to physicians, nurses, and nutritionists. Thirty-eight (51%) patients had a feeding tube placed. Twenty-eight patients (37%) were hospitalized, five of whom were hospitalized twice; of the 33 admissions, 10 (30%) were designated as secondary to mucositis by their treating physician. Mean length of hospitalization was 4.9 days (range: 1-16). This study demonstrates that mucositis-related pain and functional impairment is associated with increased use of costly health resources. Effective treatments to reduce the pain and functional impairment of oral mucositis are needed in this patient population.

Longitudinal evaluation of the oral mucositis weekly questionnaire-head and neck cancer, a patient-reported outcomes questionnaire

Quality‐of‐life instruments that measure specific functional consequences of mucositis are needed to assess the efficacy of therapeutic interventions targeted against mucositis and to guide patient care. The authors undertook a prospective, multicenter, observational study to assess the validity, reliability, and feasibility of a new instrument, the Oral Mucositis Weekly Questionnaire‐Head and Neck Cancer (OMWQ‐HN). The OMWQ‐HN is a patient‐reported outcome questionnaire that measures the symptoms of mucositis, including mouth and throat soreness (MTS), and their impact on patient well‐being and function.