Jeremy D. Young

Formulation of a model for automating infection surveillance: algorithmic detection of central-line associated bloodstream infection

OBJECTIVEnTo formulate a model for translating manual infection control surveillance methods to automated, algorithmic approaches.nnnDESIGNnWe propose a model for creating electronic surveillance algorithms by translating existing manual surveillance practices into automated electronic methods. Our model suggests that three dimensions of expert knowledge be consulted: clinical, surveillance, and informatics. Once collected, knowledge should be applied through a process of conceptualization, synthesis, programming, and testing.nnnRESULTSnWe applied our framework to central vascular catheter associated bloodstream infection surveillance, a major healthcare performance outcome measure. We found that despite major barriers such as differences in availability of structured data, in types of databases used and in semantic representation of clinical terms, bloodstream infection detection algorithms could be deployed at four very diverse medical centers.nnnCONCLUSIONSnWe present a framework that translates existing practice-manual infection detection-to an automated process for surveillance. Our experience details barriers and solutions discovered during development of electronic surveillance for central vascular catheter associated bloodstream infections at four hospitals in a variety of data environments. Moving electronic surveillance to the next level-availability at a majority of acute care hospitals nationwide-would be hastened by the incorporation of necessary data elements, vocabularies and standards into commercially available electronic health records.

Improved Virologic Suppression With HIV Subspecialty Care in a Large Prison System Using Telemedicine: An Observational Study With Historical Controls

Correctional populations have an elevated human immunodeficiency virus (HIV) prevalence, yet many individuals lack access to subspecialty care. Our study showed that HIV-infected inmates had significantly greater virologic suppression and higher CD4 T-lymphocyte counts when managed by a multidisciplinary team of subspecialists conducting clinics via telemedicine. In other studies, these outcomes have been associated with reductions on HIV-related morbidity and mortality, as well as HIV transmission.

Urinary Tract Infections : Diagnosis and Management in the Emergency Department

With the emergence of increasing resistance to common antibiotics used to treat urinary tract infections (UTIs), including ciprofloxacin and trimethoprim-sulfamethoxazole (TMP-SMX), the choice of antibiotics for these infections has become more challenging. In this article, the authors review the evidence-based guidelines for the evaluation and treatment of cystitis and pyelonephritis in the emergency department. They review the pathophysiology and describe the initial diagnostic workup, spending some time discussing the urine dipstick. The authors discuss whether hospital antibiograms are useful in making the initial antibiotic choice. The treatment section reviews the current recommendations and also highlights the use of nitrofurantoin in the treatment of uncomplicated UTIs. The authors also discuss the appropriate use of ciprofloxacin and TMP-SMX in the treatment of UTIs.

Nitazoxanide versus Metronidazole for Clostridium difficile–Associated Colitis

To the Editor—Reports of increased incidence and severity of Clostridium difficile–associated colitis have stimulated interest in the search for additional treatment options for this clinical problem. Musher et al. [1] recently reported the results of a noninferiority study that compared metronidazole with nitazoxanide for the treatment of C. difficile colitis. The authors concluded that “nitazoxanide is as effective as metronidazole” (p. 425) for this infection. Scrutiny of some aspects of the study design and analysis calls this conclusion into question. Notably, there was an unexplained exclusion of a significant number of the initially enrolled patients. The investigators compared the baseline characteristics and severity of illness in an “intent-to-treat” population; however, 32 enrolled and randomized patients were excluded before any efficacy analysis. Therefore, this was not an intent-to-treat analysis. The 110 subjects included in the primary efficacy analysis may have been very different than the initial 142 enrolled patients, and some effects of randomization were possibly lost. In addition, it is not revealed specifically what adverse events occurred among the excluded patients, and the cause of death was not revealed for any patient. The reader is told that 9.1% of the original 142 patients died, “indicating the severity of underlying disease(s) and/or the colitis” [1, p. 424]. This implies that some deaths were due to complications of C. difficile– associated colitis. This point should have been clarified. If adverse events or deaths were even peripherally related to colitis, the exclusion of these patients brings the study results into question. There were other concerns regarding this study. (1) The investigators did not analyze the minimum number of subjects required in each group and, therefore, did not achieve adequate statistical power to reject the null hypothesis. (2) When using an active control with no placeboonly group, one should employ a doubledummy design to maintain true doubleblinding. Metronidazole and nitazoxanide do not resemble one another and have different dosing schedules. Although the randomization was blinded, it appears that the study drugs were not administered in a strictly double-blind fashion. (3) The reader is not told the proportion of subjects in each group who continued to receive the original offending antibiotic(s) that presumably led to C. difficile–associated colitis. With such a small study, one cannot rely on randomization to eliminate the effects of thispotential confounder. On the basis of in vitro susceptibility data, a hamster model of disease [2], and the clinical trial by Musher et al. [1], it appears that nitazoxanide does have some efficacy in treating C. difficile–associated colitis. However, one should not conclude that it is as effective as metronidazole on the basis of this study. If noninferiority to metronidazole had been shown appropriately, the significantly higher cost of nitazoxanide makes this drug difficult to recommend as an alternative treatment. The role of nitazoxanide in current clinical practice remains undefined.

Telehealth: Increasing Access to High Quality Care by Expanding the Role of Technology in Correctional Medicine

The United States (US) has a large correctional population. However, many incarcerated persons lack access to evidence-based, up-to-date medical care, particularly by subspecialty providers, due to limitations of geography, travel, cost and other resources. The use of telehealth technologies can remove these barriers, increasing access to high quality, multidisciplinary care. Studies have shown that, with telemedicine, timely triage and medical management can be provided across many disciplines, which may lead to improved clinical outcomes and significant cost savings.