Margaret A. Fitzpatrick

Changes in bacterial epidemiology and antibiotic resistance among veterans with spinal cord injury/disorder over the past 9 years

Objective: Patients with spinal cord injury and disorder (SCI/D) have an increased risk of infection with multidrug-resistant (MDR) bacteria. We described bacterial epidemiology and resistance in patients with SCI/D at Veterans Affairs Medical Centers (VAMCs) for the past 9 years. Design: Retrospective cohort. Setting: One hundred thirty VAMCs. Participants: Veterans with SCI/D and bacterial cultures with antibiotic susceptibility testing performed between 1/1/2005–12/31/2013. Single cultures with contaminants and duplicate isolates within 30 days of initial isolates were excluded. Interventions: None. Outcomes: Trends in microbial epidemiology and antibiotic resistance. Results: Included were 216,504 isolates from 19,421 patients. Urine was the most common source and Gram-negative bacteria (GNB) were isolated most often, with 36.1% of GNB being MDR. Logistic regression models clustered by patient and adjusted for location at an SCI/D center and geographic region showed increased odds over time of vancomycin resistance in Enterococcus [adjusted odds ratio (aOR) 1.67, 95% confidence interval (CI) 1.30–2.15], while methicillin resistance in Staphylococcus aureus remained unchanged (aOR 0.90, 95% CI 0.74–1.09). There were also increased odds of fluoroquinolone resistance (aOR 1.39, 95% CI 1.31–1.47) and multidrug resistance (aOR 1.46, 95% CI 1.38–1.55) in GNB, with variability in the odds of MDR bacteria by geographic region. Conclusions: GNB are isolated frequently in Veterans with SCI/D and have demonstrated increasing resistance over the past 9 years. Priority should be given to controlling the spread of resistant bacteria in this population. Knowledge of local and regional epidemiologic trends in antibiotic resistance in patients with SCI/D may improve appropriate antibiotic prescribing.

Use of Antibiotic Prophylaxis for Tooth Extractions, Dental Implants and Periodontal Surgical Procedures

Abstract Background Guidelines for antibiotics prior to dental procedures for patients with specific cardiac conditions and prosthetic joints have changed, reducing indications for antibiotic prophylaxis. In addition to guidelines focused on patient comorbidities, systematic reviews specific to dental extractions and implants support preprocedure antibiotics for all patients. However, data on dentist adherence to these recommendations are scarce. Methods This was a cross-sectional study of veterans undergoing tooth extractions, dental implants, and periodontal procedures. Patients receiving antibiotics for oral or nonoral infections were excluded. Data were collected through manual review of the health record. Results Of 183 veterans (mean age, 62 years; 94.5% male) undergoing the included procedures, 82.5% received antibiotic prophylaxis (mean duration, 7.1 ± 1.6 days). Amoxicillin (71.3% of antibiotics) and clindamycin (23.8%) were prescribed most frequently; 44.7% of patients prescribed clindamycin were not labeled as penicillin allergic. Of those who received prophylaxis, 92.1% received postprocedure antibiotics only, 2.6% received preprocedural antibiotics only, and 5.3% received pre- and postprocedure antibiotics. When prophylaxis was indicated, 87.3% of patients received an antibiotic. However, 84.9% received postprocedure antibiotics when preprocedure administration was indicated. While the majority of antibiotics were indicated, only 8.2% of patients received antibiotics appropriately. The primary reason was secondary to prolonged duration. Three months postprocedure, there were no occurrences of Clostridium difficile infection, infective endocarditis, prosthetic joint infections, or postprocedure oral infections. Conclusion The majority of patients undergoing a dental procedure received antibiotic prophylaxis as indicated. Although patients for whom antibiotic prophylaxis was indicated should have received a single preprocedure dose, most antibiotics were prescribed postprocedure. Dental stewardship efforts should ensure appropriate antibiotic timing, indication, and duration.

Multidrug-resistant Acinetobacter: Risk factors and outcomes in veterans with spinal cord injuries and disorders

Background Multidrug‐resistant (MDR) Acinetobacter is a growing concern and has been identified as a serious threat by the Centers for Disease Control and Prevention. However, there is little information on MDR Acinetobacter in individuals with spinal cord injuries and disorders (SCI/Ds). Therefore, the objective of this study was to identify risk factors for, and assess outcomes of, MDR Acinetobacter in veterans with SCI/Ds. Methods: This was a retrospective cohort study from January 1, 2012‐December 31, 2013, using national Veterans Affairs medical encounter and microbiology data. Results: A total of 773 Acinetobacter cultures were identified in 571 patients, of which 58.9% were MDR. Inpatient culture, sputum and other specimen type, receipt of antibiotics within 90 days before culture date, and pressure ulcers were identified as independent predictors of MDR Acinetobacter. Highest odds of MDR Acinetobacter were seen with previous antibiotic use (odds ratio, 7.27; 95% confidence interval, 2.59‐20.54). Thirty‐day mortality was 5.3% in this study. Multidrug resistance, previous mechanical ventilation 90 days before the culture, and cancer were all independent risk factors for 30‐day mortality. Conclusions: There should be increased efforts to highlight the importance of antimicrobial stewardship to improve infection control to help limit spread of Acinetobacter in health care settings.

Influence of drug class and healthcare setting on systemic antifungal expenditures in the United States, 2005–15

PURPOSE Overall and specific class trends in systemic antifungal expenditures in various U.S. healthcare settings from 2005 through 2015 were evaluated. METHODS Systemic antifungal expenditures from January 1, 2005, through December 31, 2015, were obtained from the QuintilesIMS National Sales Perspective database, which provides a statistically valid projection of medication purchases from multiple markets throughout the United States. Summary data for total antifungal expenditures over the entire period are reported, as are growth and the percentage change in expenditures from one year to the next. Expenditures were also assessed specifically by year, class, and healthcare setting. Expenditure trends over the study period were assessed using simple linear trend regression models. RESULTS Overall expenditures for the 11-year period were

Pre-operative screening for asymptomatic bacteriuria and associations with post-operative outcomes in patients with spinal cord injury

9.37 billion. The greatest proportion of expenditures occurred in nonfederal hospitals (47.2%) and for triazoles (57.6%). From 2005 through 2015, total expenditures decreased from

Long-term prescribing of nitrofurantoin for urinary tract infections (UTI) in veterans with spinal cord injury (SCI)

1.1 billion to

Effect of varying federal definitions on prevalence and characteristics associated with carbapenem-resistant Enterobacteriaceae in veterans with spinal cord injury

894 million (-18.8%, p = 0.09); however, expenditures in clinics and retail pharmacies increased (202%, p < 0.01, and 13.8%, p = 0.04, respectively), a trend most pronounced after 2012. Expenditures for flucytosine also increased (968.1%, p < 0.01), particularly in clinics where there was a dramatic 6,640.9% increase (p < 0.01). CONCLUSION From 2005 through 2015, an increase in systemic antifungal expenditures was observed in community settings, despite an overall decrease in total antifungal expenditures in the United States. Large increases in flucytosine expenditures were observed, particularly in the community.

Risk factors for community-associated multidrug-resistant Pseudomonas aeruginosa in veterans with spinal cord injury and disorder: a retrospective cohort study

Context: Screening for asymptomatic bacteriuria (ASB) before non-urologic surgery is common but of unclear benefit. Our aim was to describe pre-operative ASB screening and post-operative outcomes in patients with neurogenic bladder due to spinal cord injury (SCI). Methods: This was a descriptive retrospective cohort study of adults with SCI undergoing neurosurgical spine or orthopedic lower limb surgery from 10/1/2012-9/30/2014 at Veterans Affairs (VA) medical centers. National VA datasets and medical record review was used to describe frequency of pre-operative ASB screening, presence of ASB, and association with post-operative surgical site infection, urinary tract infection, and hospital readmission. Results: 175 patients were included. Although over half of patients had pre-operative ASB screening, only 30.8% actually had pre-operative ASB. 15.2% of patients screened were treated for ASB with antibiotics before surgery. Post-operative urinary tract infection (UTI) or surgical site infection (SSI) occurred in 10 (5.7%) patients, and 20 patients (11.4%) were readmitted within 30 days. Neither ASB screening nor the presence of pre-operative ASB were associated with these post-op outcomes (p > 0.2 for all). Conclusion: Pre-operative ASB screening is common in patients with SCI undergoing elective spine and lower limb surgery, although ASB occurs in less than 1/3rd of cases. There were no associations between pre-operative ASB and outcomes. Further studies evaluating the clinical benefit of this practice in patients with SCI should be performed.

Prevalence and Factors Associated With Multidrug-Resistant Gram-Negative Organisms in Patients With Spinal Cord Injury

Context/Objective To evaluate the impact of long-term nitrofurantoin for UTI prophylaxis in veterans with SCI. Design Matched pairs study. Setting Veterans cared for at VA facilities from 10/1/2012-9/30/2013. Participants Veterans. Interventions n/a. Outcomes measures UTI, positive urine cultures, resistant cultures. Methods Cases receiving long-term nitrofurantoin (≥90 days supply) were matched to controls by facility. Controls were patients who did not receive long-term nitrofurantoin with a history of ≥3 positive urine cultures and at least one diagnosis of UTI or asymptomatic bacteriuria in the previous year. Results 122 SCI cases were identified and matched to 196 controls. After adjusting for differences in baseline demographic characteristics, UTIs were less frequent in cases (OR = 0.60 [95% CI 0.44-0.72]). Cases had a greater mean number of days between positive urine cultures as compared to controls (<0.0001). Cases were more likely to have isolates resistant to nitrofurantoin (P ≤ 0.0001); however, the frequency of multi-drug resistant organisms isolated from the urine was not significantly different. Conclusions Long-term prescription of nitrofurantoin may reduce UTIs in veterans with SCI and there is no evidence that it promotes multi-drug resistance. Future prospective studies should be conducted prior to incorporating routine use of long-term nitrofurantoin into clinical care.

The Feasibility of an Infection Control Safe Zone in a Spinal Cord Injury Unit

HIGHLIGHTSPatients with spinal cord injury have high carbapenem‐resistant Enterobacteriaceae (CRE) prevalence as opposed to the general population.Variability in federal surveillance definitions affects CRE prevalence.Inclusion of ertapenem resistance in the definition leads to higher CRE prevalence.Almost all CRE was isolated from high‐complexity, urban Department of Veterans Affairs medical centers. Background: Patients with spinal cord injury (SCI) have a high risk for multidrug‐resistant organisms, including carbapenem‐resistant Enterobacteriaceae (CRE). Accurate and easily applied definitions are critical to identify CRE. This study describes CRE and associated characteristics in veterans with SCI per Centers for Disease Control and Prevention (CDC) and Department of Veterans Affairs (VA) definitions. Methods: A retrospective cohort of veterans with SCI and more than 1 culture with Escherichia coli, Klebsiella spp and/or Enterobacter spp between 2012 and 2013 was examined. Antibiotic susceptibility criteria of pre‐2015 (CDC1) and post‐2015 (CDC2) CDC definitions and pre‐2017 (VA1) and post‐2017 (VA2) VA definitions were used to identify CRE. CRE prevalence and characteristics are described for isolates meeting each definition, and agreement was assessed with the Cohen kappa. Results: We reviewed 21,514 isolates cultured from 6,974 veterans; 423 isolates met any CRE definition. Although agreement among definitions was high (kappa=0.82–0.93), definitions including ertapenem resistance led to higher CRE prevalence (VA1=1.7% and CDC2=1.9% vs VA2=1.4% and CDC1=1.5%). Forty‐four of 142 VA facilities had more than 1 CRE case defined by VA2; 10 facilities accounted for 60% of CRE cases. Almost all CRE was isolated from high‐complexity, urban facilities, and the South had the highest proportion of CRE. Conclusions: Varying federal definitions give different CRE frequencies in a high‐risk population. Definitions including ertapenem resistance resulted in higher CRE prevalence but may overemphasize noncarbapenemase isolates. Thus, both federal definitions now highlight the importance of carbapenemase testing.