Joel C. Boggan

Pediatric-Specific Antimicrobial Susceptibility Data and Empiric Antibiotic Selection

OBJECTIVE: Duke University Health System (DUHS) generates annual antibiograms combining adult and pediatric data. We hypothesized significant susceptibility differences exist for pediatric isolates and that distributing these results would alter antibiotic choices. METHODS: Susceptibility rates for Escherichia coli isolates from patients aged ≤12 years between July 2009 and September 2010 were compared with the 2009 DUHS antibiogram. Pediatric attending and resident physicians answered case-based vignettes about children aged 3 months and 12 years with urinary tract infections. Each vignette contained 3 identical scenarios with no antibiogram, the 2009 DUHS antibiogram, and a pediatric-specific antibiogram provided. Effective antibiotics exhibited >80% in vitro susceptibility. Frequency of antibiotic selection was analyzed by using descriptive statistics. RESULTS: Three hundred seventy-five pediatric isolates were identified. Pediatric isolates were more resistant to ampicillin and trimethoprim-sulfamethoxazole (TMP-SMX) and less resistant to amoxicillin-clavulanate and ciprofloxacin (P < .0005 for all). Seventy-five resident and attending physicians completed surveys. In infant vignettes, physicians selected amoxicillin-clavulanate (P < .05) and nitrofurantoin (P < .01) more often and TMP-SMX (P < .01) less often with pediatric-specific data. Effective antibiotic choices increased from 68.6% to 82.2% (P = .06) to 92.5% (P < .01) across scenarios. In adolescent vignettes, providers reduced TMP-SMX use from 66.2% to 42.6% to 19.0% (P < .01 for both). Effective antibiotic choices increased from 32.4% to 57.4% to 79.4% (P < .01 and P = .01). CONCLUSIONS: Pediatric E. coli isolates differ significantly in antimicrobial susceptibility at our institution, particularly to frequently administered oral antibiotics. Knowledge of pediatric-specific data altered empirical antibiotic choices in case vignettes. Care of pediatric patients could be improved with use of a pediatric-specific antibiogram.

Poor Positive Predictive Value of Lyme Disease Serologic Testing in an Area of Low Disease Incidence

BACKGROUND Lyme disease is diagnosed by 2-tiered serologic testing in patients with a compatible clinical illness, but the significance of positive test results in low-prevalence regions has not been investigated. METHODS We reviewed the medical records of patients who tested positive for Lyme disease with standardized 2-tiered serologic testing between 2005 and 2010 at a single hospital system in a region with little endemic Lyme disease. Based on clinical findings, we calculated the positive predictive value of Lyme disease serology. Next, we reviewed the outcome of serologic testing in patients with select clinical syndromes compatible with disseminated Lyme disease (arthritis, cranial neuropathy, or meningitis). RESULTS During the 6-year study period 4723 patients were tested for Lyme disease, but only 76 (1.6%) had positive results by established laboratory criteria. Among 70 seropositive patients whose medical records were available for review, 12 (17%; 95% confidence interval, 9%-28%) were found to have Lyme disease (6 with documented travel to endemic regions). During the same time period, 297 patients with a clinical illness compatible with disseminated Lyme disease underwent 2-tiered serologic testing. Six of them (2%; 95% confidence interval, 0.7%-4.3%) were seropositive, 3 with documented travel and 1 who had an alternative diagnosis that explained the clinical findings. CONCLUSIONS In this low-prevalence cohort, fewer than 20% of positive Lyme disease tests are obtained from patients with clinically likely Lyme disease. Positive Lyme disease test results may have little diagnostic value in this setting.

Guideline-based decision support has a small, non-sustained effect on transthoracic echocardiography ordering frequency

Background Guidance for appropriate utilisation of transthoracic echocardiograms (TTEs) can be incorporated into ordering prompts, potentially affecting the number of requests. Methods We incorporated data from the 2011 Appropriate Use Criteria for Echocardiography, the 2010 National Institute for Clinical Excellence Guideline on Chronic Heart Failure, and American College of Cardiology Choosing Wisely list on TTE use for dyspnoea, oedema and valvular disease into electronic ordering systems at Durham Veterans Affairs Medical Center. Our primary outcome was TTE orders per month. Secondary outcomes included rates of outpatient TTE ordering per 100 visits and frequency of brain natriuretic peptide (BNP) ordering prior to TTE. Outcomes were measured for 20 months before and 12 months after the intervention. Results The number of TTEs ordered did not decrease (338±32 TTEs/month prior vs 320±33 afterwards, p=0.12). Rates of outpatient TTE ordering decreased minimally post intervention (2.28 per 100 primary care/cardiology visits prior vs 1.99 afterwards, p<0.01). Effects on TTE ordering and ordering rate significantly interacted with time from intervention (p<0.02 for both), as the small initial effects waned after 6 months. The percentage of TTE orders with preceding BNP increased (36.5% prior vs 42.2% after for inpatients, p=0.01; 10.8% prior vs 14.5% after for outpatients, p<0.01). Conclusions Ordering prompts for TTEs initially minimally reduced the number of TTEs ordered and increased BNP measurement at a single institution, but the effect on TTEs ordered was likely insignificant from a utilisation standpoint and decayed over time.

The Burden of Burnout An Assessment of Burnout Among Internal Medicine Residents After the 2011 Duty Hour Changes

This study sought to determine burnout prevalence and factors associated with burnout in internal medicine residents after introduction of the 2011 ACGME duty hour rules. Burnout was evaluated using an anonymized, abbreviated version of the Maslach Burnout Inventory. Surveys were collected biweekly for 48 weeks during the 2013-2014 academic year. Burnout severity was compared across subgroups and time. A score of 3 or higher signified burnout. Overall, 944 of 3936 (24%) surveys were completed. The mean burnout score across all surveys was 2.8. Categorical residents had higher burnout severity than noncategorical residents (2.9 vs 2.7, P = .005). Postgraduate year 2 residents had the highest burnout severity by year (3.1, P < .001). Residents on inpatient rotations had higher burnout severity than residents on outpatient or consultation rotations (3.1 vs 2.2 vs 2.2, P < .001). Night float rotations had the highest severity (3.8). Burnout remains a significant problem even with recent duty hour modifications.

An Automated Surveillance Strategy to Identify Infectious Complications After Cardiac Implantable Electronic Device Procedures.

Background.  The optimum approach for infectious complication surveillance for cardiac implantable electronic device (CIED) procedures is unclear. We created an automated surveillance tool for infectious complications after CIED procedures. Methods.  Adults having CIED procedures between January 1, 2005 and December 31, 2011 at Duke University Hospital were identified retrospectively using International Classification of Diseases, 9th revision (ICD-9) procedure codes. Potential infections were identified with combinations of ICD-9 diagnosis codes and microbiology data for 365 days postprocedure. All microbiology-identified and a subset of ICD-9 code-identified possible cases, as well as a subset of procedures without microbiology or ICD-9 codes, were reviewed. Test performance characteristics for specific queries were calculated. Results.  Overall, 6097 patients had 7137 procedures. Of these, 1686 procedures with potential infectious complications were identified: 174 by both ICD-9 code and microbiology, 14 only by microbiology, and 1498 only by ICD-9 criteria. We reviewed 558 potential cases, including all 188 microbiology-identified cases, 250 randomly selected ICD-9 cases, and 120 with neither. Overall, 65 unique infections were identified, including 5 of 250 reviewed cases identified only by ICD-9 codes. Queries that included microbiology data and ICD-9 code 996.61 had good overall test performance, with sensitivities of approximately 90% and specificities of approximately 80%. Queries with ICD-9 codes alone had poor specificity. Extrapolation of reviewed infectious rates to nonreviewed cases yields an estimated rate of infection of 1.3%. Conclusions.  Electronic queries with combinations of ICD-9 codes and microbiologic data can be created and have good test performance characteristics for identifying likely infectious complications of CIED procedures.

Vaginal Self-Sampling for Human Papillomavirus Infection as a Primary Cervical Cancer Screening Tool in a Haitian Population.

Background Human papillomavirus (HPV) testing as primary cervical cancer screening has not been studied in Caribbean women. We tested vaginal self-collection versus physician cervical sampling in a population of Haitian women. Methods Participants were screened for high-risk HPV with self-performed vaginal and clinician-collected cervical samples using Hybrid Capture 2 assays (Qiagen, Gaithersburg, MD). Women positive by either method then underwent colposcopy with biopsy of all visible lesions. Sensitivity and positive predictive value were calculated for each sample method compared with biopsy results, with &kgr; statistics performed for agreement. McNemar tests were performed for differences in sensitivity at ≥cervical intraepithelial neoplasia (CIN)-I and ≥CIN-II. Results Of 1845 women screened, 446 (24.3%) were HPV positive by either method, including 105 (5.7%) only by vaginal swab and 53 (2.9%) only by cervical swab. Vaginal and cervical samples were 91.4% concordant (&kgr; = 0.73 [95% confidence interval, 0.69–0.77], P < 0.001). Overall, 133 HPV-positive women (29.9%) had CIN-I, whereas 32 (7.2%) had ≥CIN-II. The sensitivity of vaginal swabs was similar to cervical swabs for detecting ≥CIN-I (89.1% vs. 87.9%, respectively; P = 0.75) lesions and ≥CIN-II disease (87.5% vs. 96.9%, P = 0.18). Eighteen of 19 cases of CIN-III and invasive cancer were found by both methods. Conclusions Human papillomavirus screening via self-collected vaginal swabs or physician-collected cervical swabs are feasible options in this Haitian population. The agreement between cervical and vaginal samples was high, suggesting that vaginal sample–only algorithms for screening could be effective for improving screening rates in this underscreened population.

Variability in performance measures for assessment of hypertension control

BACKGROUND Definitions of multiple performance measures exist for the assessment of blood pressure control; however, limited data on how these technical variations may affect actual measured performance are available. METHODS We evaluated patients with hypertension followed routinely by cardiologists at Duke University Health System from 2009 to 2010. Provider hypertension control was compared based on reading at the last clinic visit vs the average blood pressure across all visits. The impact of home blood pressure measurements and patient exclusions endorsed by the American Heart Association, the American College of Cardiology, and the Physician Consortium for Performance Improvement were evaluated using medical record reviews. RESULTS Among 5,552 hypertensive patients, the rate of blood pressure control based on last clinic visit was 69.1%; however, significant clinic-to-clinic variability was seen in serial clinic blood pressure measurements in individual patients (average 18 mm Hg). As a result, provider performance ratings varied considerably depending on whether a single reading or average blood pressure reading was used. The inclusion of home blood pressure measurements resulted in modestly higher rates of blood pressure control performance (+6% overall). Similarly, excluding patients who met guideline-recommended exclusion criteria increased blood pressure control rates only slightly (+3% overall). In contrast, excluding patients who were on 2 or more antihypertensive medications would have raised blood pressure control rates to 96% overall. CONCLUSION Depending on definitions used, overall and provider-specific blood pressure control rates can vary considerably. Technical aspects of blood pressure performance measures may affect perceived quality gaps and comparative provider ratings.

Awareness of Cervical Cancer Causes and Predeterminants of Likelihood to Screen among Women in Haiti

Objectives Cervical cancer is the leading cause of cancer deaths among women in Haiti. Given this high disease burden, we sought to better understand womens knowledge of its causes and the sociodemographic and health correlates of cervical cancer screening. Materials and Methods Participants were 410 adult women presenting at clinics in Léogâne and Port-au-Prince, Haiti. We used bivariate and multivariate logic regression to identify correlates of Pap smear receipt. Results Only 29% of respondents had heard of human papillomavirus (HPV), whereas 98% were aware of cervical cancer. Of those aware of cervical cancer, 12% believed that sexually transmitted infections (STIs) cause it, and only 4% identified HPV infection as the cause. Women with a previous sexually transmitted infection were more likely to have had Pap smear (34% vs 71%, odds ratio = 3.45; 95% CI = 1.57–7.59). Screening was also more likely among women who were older than the age of 39 years, better educated, and employed (all p < .05). Almost all women (97%) were willing to undergo cervical cancer screening. Conclusions This sample of Haitian women had limited awareness of HPV and cervical cancer causes; but when provided with health information, they saw the benefits of cancer screening. Future initiatives should provide health education messages, with efforts targeting young and at-risk women.

Reductions in telemetry order duration do not reduce telemetry utilization.

The Society of Hospital Medicine’s Adult Choosing Wisely measures include not ordering “continuous telemetry monitoring outside of the ICU [intensive care unit] without using a protocol that governs continuation.” Current guidelines for cardiac monitoring use recommend minimum durations for all adult class I and most class II indications. However, telemetry ordering often fails to include timing or criteria for discontinuation. We determined the impact of a reduction in telemetry order duration within our hospital, hypothesizing this reduction would lead to earlier reassessment of telemetry need and therefore decrease overall utilization.

912Assessment of Automated Surveillance Strategies to Identify Infectious Complications Following Implanted Cardiac Device Procedures

Infectious Complications Following Implanted Cardiac Device Procedures Joel C. Boggan, MD, MPH; Arthur W. Baker, MD; Kristen V. Dicks, MD; Michael J. Durkin, MD; Sarah S. Lewis, MD; Rebekah W. Moehring, MD, MPH; Luke F. Chen, MBBS, MPH, CIC, FRACP; Lauren Knelson, MSPH; Deverick J. Anderson, MD, MPH, FSHEA; Medicine, Durham Veterans Affairs Medical Center, Durham, NC; Department of Medicine, Duke University Medical Center, Durham, NC; Duke University Medical Center, Durham, NC; Division of Infectious Diseases, Duke University Medical Center, Durham, NC; Duke University CDC Prevention Epicenter Program, Durham, NC