Monica Sikka

Severe influenza in 33 US hospitals, 2013–2014: Complications and risk factors for death in 507 patients

BACKGROUND Influenza A (H1N1) pdm09 became the predominant circulating strain in the United States during the 2013-2014 influenza season. Little is known about the epidemiology of severe influenza during this season. METHODS A retrospective cohort study of severely ill patients with influenza infection in intensive care units in 33 US hospitals from September 1, 2013, through April 1, 2014, was conducted to determine risk factors for mortality present on intensive care unit admission and to describe patient characteristics, spectrum of disease, management, and outcomes. RESULTS A total of 444 adults and 63 children were admitted to an intensive care unit in a study hospital; 93 adults (20.9%) and 4 children (6.3%) died. By logistic regression analysis, the following factors were significantly associated with mortality among adult patients: older age (>65 years, odds ratio, 3.1 [95% CI, 1.4-6.9], P=.006 and 50-64 years, 2.5 [1.3-4.9], P=.007; reference age 18-49 years), male sex (1.9 [1.1-3.3], P=.031), history of malignant tumor with chemotherapy administered within the prior 6 months (12.1 [3.9-37.0], P<.001), and a higher Sequential Organ Failure Assessment score (for each increase by 1 in score, 1.3 [1.2-1.4], P<.001). CONCLUSION Risk factors for death among US patients with severe influenza during the 2013-2014 season, when influenza A (H1N1) pdm09 was the predominant circulating strain type, shifted in the first postpandemic season in which it predominated toward those of a more typical epidemic influenza season.

Bacterial and viral co-infections complicating severe influenza: Incidence and impact among 507 U.S. patients, 2013–14

Abstract Background Influenza acts synergistically with bacterial co-pathogens. Few studies have described co-infection in a large cohort with severe influenza infection. Objectives To describe the spectrum and clinical impact of co-infections. Study design Retrospective cohort study of patients with severe influenza infection from September 2013 through April 2014 in intensive care units at 33 U.S. hospitals comparing characteristics of cases with and without co-infection in bivariable and multivariable analysis. Results Of 507 adult and pediatric patients, 114 (22.5%) developed bacterial co-infection and 23 (4.5%) developed viral co-infection. Staphylococcus aureus was the most common cause of co-infection, isolated in 47 (9.3%) patients. Characteristics independently associated with the development of bacterial co-infection of adult patients in a logistic regression model included the absence of cardiovascular disease (OR 0.41 [0.23–0.73], p=0.003), leukocytosis (>11K/μl, OR 3.7 [2.2–6.2], p<0.001; reference: normal WBC 3.5–11K/μl) at ICU admission and a higher ICU admission SOFA score (for each increase by 1 in SOFA score, OR 1.1 [1.0–1.2], p=0.001). Bacterial co-infections (OR 2.2 [1.4–3.6], p=0.001) and viral co-infections (OR 3.1 [1.3–7.4], p=0.010) were both associated with death in bivariable analysis. Patients with a bacterial co-infection had a longer hospital stay, a longer ICU stay and were likely to have had a greater delay in the initiation of antiviral administration than patients without co-infection (p<0.05) in bivariable analysis. Conclusions Bacterial co-infections were common, resulted in delay of antiviral therapy and were associated with increased resource allocation and higher mortality.

Serratia marcescens bacteremia because of contaminated prefilled heparin and saline syringes: A multi-state report

A national outbreak of Serratia marcescens bacteremia because of contaminated prefilled heparin and saline syringes led to their recall. We evaluated the clinical impact of this outbreak in 57 patients at 3 centers. All patients were symptomatic and were treated with intravenous antibiotics with a fatal outcome in 1 patient.

Predictors of Hospital Readmission in Patients Receiving Outpatient Parenteral Antimicrobial Therapy.

Outpatient parenteral antimicrobial therapy (OPAT) is increasingly used, and unfortunately, readmissions during OPAT are common. The purpose of this study was to identify predictors of hospital readmission among patients receiving OPAT.

Microbiologic and Clinical Epidemiologic Characteristics of the Chicago Subset of a Multistate Outbreak of Serratia marcescens Bacteremia

We describe 22 patients from a multistate outbreak of Serratia marcescens bacteremia that was linked to contaminated prefilled syringes of heparin and saline supplied by 1 manufacturer. Contents of unused syringes were cultured in pools; samples from 25 (5.3%) of 472 syringes grew S. marcescens. Despite good clinical outcomes overall, patients had substantial morbidity.

Pharmacokinetics of telavancin at fixed doses in normal- body-weight and obese (classes I, II, and III) adult subjects

ABSTRACT A recommended total-body-weight (TBW) dosing strategy for telavancin may not be optimal in obese patients. The primary objective of this study was to characterize and compare the pharmacokinetics (PK) of telavancin across four body size groups: normal to overweight and obese classes I, II, and III. Healthy adult subjects (n = 32) received a single, weight-stratified, fixed dose of 500 mg (n = 4), 750 mg (n = 8), or 1,000 mg (n = 20) of telavancin. Noncompartmental PK analyses revealed that subjects with a body mass index (BMI) of ≥40 kg/m2 had a higher volume of distribution (16.24 ± 2.7 liters) than subjects with a BMI of <30 kg/m2 (11.71 ± 2.6 liters). The observed area under the concentration-time curve from time zero to infinity (AUC0–∞) ranged from 338.1 to 867.3 mg · h/liter, with the lowest exposures being in subjects who received 500 mg. AUC0–∞ values were similar among obese subjects who received 1,000 mg. A two-compartment population PK model best described the plasma concentration-time profile of telavancin when adjusted body weight (ABW) was included as a predictive covariate. Fixed doses of 750 mg and 1,000 mg had similar target attainment probabilities for efficacy as doses of 10 mg/kg of body weight based on ABW and TBW, respectively. However, the probability of achieving a target area under the concentration-time curve from time zero to 24 h of ≥763 mg · h/liter in association with acute kidney injury was highest (19.7%) with TBW-simulated dosing and lowest (0.4%) at the 750-mg dose. These results suggest that a fixed dose of 750 mg is a safe and effective alternative to telavancin doses based on TBW or ABW for the treatment of obese patients with normal renal function and Staphylococcus aureus infections. (This study has been registered at ClinicalTrials.gov under identifier NCT02753855.)

The Impact of Recurrent Clostridium difficile Infection on Patients’ Prevention Behaviors

OBJECTIVE To determine the impact of recurrent Clostridium difficile infection (RCDI) on patient behaviors following illness. METHODS Using a computer algorithm, we searched the electronic medical records of 7 Chicago-area hospitals to identify patients with RCDI (2 episodes of CDI within 15 to 56 days of each other). RCDI was validated by medical record review. Patients were asked to complete a telephone survey. The survey included questions regarding general health, social isolation, symptom severity, emotional distress, and prevention behaviors. RESULTS In total, 119 patients completed the survey (32%). On average, respondents were 57.4 years old (standard deviation, 16.8); 57% were white, and ~50% reported hospitalization for CDI. At the time of their most recent illness, patients rated their diarrhea as high severity (58.5%) and their exhaustion as extreme (30.7%). Respondents indicated that they were very worried about getting sick again (41.5%) and about infecting others (31%). Almost 50% said that they have washed their hands more frequently (47%) and have increased their use of soap and water (45%) since their illness. Some of these patients (22%-32%) reported eating out less, avoiding certain medications and public areas, and increasing probiotic use. Most behavioral changes were unrelated to disease severity. CONCLUSION Having had RCDI appears to increase prevention-related behaviors in some patients. While some behaviors are appropriate (eg, handwashing), others are not supported by evidence of decreased risk and may negatively impact patient quality of life. Providers should discuss appropriate prevention behaviors with their patients and should clarify that other behaviors (eg, eating out less) will not affect their risk of future illness. Infect Control Hosp Epidemiol. 2017;38:1351-1357.

Contact patterns during cleaning of vomitus: A simulation study

HighlightsCleaning of simulated vomitus was relatively quick.Cleaners infrequently touched their own bodies while cleaning.Cleaners touched the cleaning cart more often than other surfaces, on average.Each participant used different cleaning practices, but used similar cleaning practices each time he or she cleaned.Few cleaners followed the recommended protocol for cleaning bodily fluids.Following the recommended protocol for cleaning bodily fluids was associated with fewer surface contacts and improved cleaning quality. Background: Environmental service workers cleaning bodily fluids may transfer pathogens through the environment and to themselves through contacts. Methods: Participants with experience in cleaning of hospital environments were asked to clean simulated vomitus using normal practices in a simulated patient room while being videorecorded. Contacts with environmental surfaces and self were later observed. Results: In 21 experimental trials with 7 participants, environmental surfaces were contacted 26.8 times per trial, at a frequency of 266 contacts per hour, on average. Self‐contact occurred in 9 of 21 trials, and involved 1‐18 contacts, mostly to the upper body. The recommended protocol of cleaning bodily fluids was followed by a minority of participants (2 of 7), and was associated with fewer surface contacts, improved cleaning quality, and different tool use. Participants used different cleaning practices, but each employed similar practices each time they performed an experimental trial. Conclusions: Training in the use of the recommended protocol may standardize cleaning practices and reduce the number of surface contacts.

Understanding Staff Perceptions about Klebsiella pneumoniae Carbapenemase–Producing Enterobacteriaceae Control Efforts in Chicago Long-Term Acute Care Hospitals

OBJECTIVE To identify differences in organizational culture and better understand motivators to implementation of a bundle intervention to control Klebsiella pneumoniae carbapenemase-producing Enterobacteriaceae (KPC). DESIGN Mixed-methods study. SETTING Four long-term acute care hospitals (LTACHs) in Chicago. PARTICIPANTS LTACH staff across 3 strata of employees (administration, midlevel management, and frontline clinical workers). METHODS Qualitative interviews or focus groups and completion of a quantitative questionnaire. RESULTS Eighty employees (frontline, 72.5%; midlevel, 17.5%; administration, 10%) completed surveys and participated in qualitative discussions in August 2012. Although 82.3% of respondents felt that quality improvement was a priority at their LTACH, there were statistically significant differences in organizational culture between staff strata, with administrative-level having higher organizational culture scores (ie, more favorable responses) than midlevel or frontline staff. When asked to rank the success of the KPC control program, mean response was 8.0 (95% confidence interval, 7.6-8.5), indicating a high level of agreement with the perception that the program was a success. Patient safety and personal safety were reported most often as personal motivators for intervention adherence. The most convergent theme related to prevention across groups was that proper hand hygiene is vital to prevention of KPC transmission. CONCLUSIONS Despite differences in organizational culture across 3 strata of LTACH employees, the high degree of convergence in motivation, understanding, and beliefs related to implementation of a KPC control bundle suggests that all levels of staff may be able to align perspectives when faced with a key infection control problem and quality improvement initiative.