Sarah H. Yi

Bloodstream Infection Rates in Outpatient Hemodialysis Facilities Participating in a Collaborative Prevention Effort: A Quality Improvement Report

BACKGROUND Bloodstream infections (BSIs) cause substantial morbidity in hemodialysis patients. In 2009, the US Centers for Disease Control and Prevention (CDC) sponsored a collaborative project to prevent BSIs in outpatient hemodialysis facilities. We sought to assess the impact of a set of interventions on BSI and access-related BSI rates in participating facilities using data reported to the CDCs National Healthcare Safety Network (NHSN). STUDY DESIGN Quality improvement project. SETTING & PARTICIPANTS Patients in 17 outpatient hemodialysis facilities that volunteered to participate. QUALITY IMPROVEMENT PLAN Facilities reported monthly event and denominator data to NHSN, received guidance from the CDC, and implemented an evidence-based intervention package that included chlorhexidine use for catheter exit-site care, staff training and competency assessments focused on catheter care and aseptic technique, hand hygiene and vascular access care audits, and feedback of infection and adherence rates to staff. OUTCOMES Crude and modeled BSI and access-related BSI rates. MEASUREMENTS Up to 12 months of preintervention (January 2009 through December 2009) and 15 months of intervention period (January 2010 through March 2011) data from participating centers were analyzed. Segmented regression analysis was used to assess changes in BSI and access-related BSI rates during the preintervention and intervention periods. RESULTS Most (65%) participating facilities were hospital based. Pooled mean BSI and access-related BSI rates were 1.09 and 0.73 events per 100 patient-months during the preintervention period and 0.89 and 0.42 events per 100 patient-months during the intervention period, respectively. Modeled rates decreased 32% (P = 0.01) for BSIs and 54% (P < 0.001) for access-related BSIs at the start of the intervention period. LIMITATIONS Participating facilities were not representative of all outpatient hemodialysis centers nationally. There was no control arm to this quality improvement project. CONCLUSIONS Facilities participating in a collaborative successfully decreased their BSI and access-related BSI rates. The decreased rates appeared to be maintained in the intervention period. These findings suggest that improved implementation of recommended practices can reduce BSIs in hemodialysis centers.

Activity of Commonly Used Antimicrobial Prophylaxis Regimens against Pathogens Causing Coronary Artery Bypass Graft and Arthroplasty Surgical Site Infections in the United States, 2006–2009

BACKGROUND Coronary artery bypass graft (CABG) and primary arthroplasty surgical site infection (SSI) rates are declining slower than other healthcare-associated infection rates. We examined antimicrobial prophylaxis (AMP) regimens used for these operations and compared their spectrum of activity against reported SSI pathogens. METHODS Pathogen distributions of CABG and hip/knee arthroplasty complex SSIs (deep and organ/space) reported to the National Healthcare Safety Network (NHSN) from 2006 through 2009 and AMP regimens (same procedures and time period) reported to the Surgical Care Improvement Project (SCIP) were analyzed. Regimens were categorized as standard (cefazolin or cefuroxime), β-lactam allergy (vancomycin or clindamycin with or without an aminoglycoside), and extended spectrum (vancomycin and/or an aminoglycoside with cefazolin or cefuroxime). AMP activity of each regimen was predicted on the basis of pathogen susceptibility reports and published spectra of antimicrobial activity. RESULTS There were 6,263 CABG and arthroplasty complex SSIs reported (680,489 procedures; 880 NHSN hospitals). Among 6,574 pathogens reported, methicillin-sensitive Staphylococcus aureus (23%), methicillin-resistant S. aureus (18%), coagulase-negative staphylococci (17%), and Enterococcus species (7%) were most common. AMP regimens for 2,435,703 CABG and arthroplasty procedures from 3,330 SCIP hospitals were analyzed. The proportion of pathogens predictably susceptible to standard (used in 75% of procedures), β-lactam (12%), and extended-spectrum (8%) regimens was 41%-45%, 47%-96%, and 81%-96%, respectively. CONCLUSION Standard AMP, used in three-quarters of CABG and primary arthroplasty procedures, has inadequate activity against more than half of SSI pathogens reported. Alternative strategies may be needed to prevent SSIs caused by pathogens resistant to standard AMP regimens.

Prevalence of probiotic use among inpatients: A descriptive study of 145 U.S. hospitals

BACKGROUND To inform clinical guidance, public health efforts, and research directions, probiotic use in U.S. health care needs to be better understood. This work aimed to assess the prevalence of inpatient probiotic use in a sample of U.S. hospitals. METHODS Probiotic use among patients discharged in 2012 was estimated using the MarketScan Hospital Drug Database. In addition, the annual trend in probiotic use (2006-2012) was assessed among a subset of hospitals. RESULTS Among 145 hospitals with 1,976,167 discharges in 2012, probiotics were used in 51,723 (2.6%) of hospitalizations occurring in 139 (96%) hospitals. Patients receiving probiotics were 9 times more likely to receive antimicrobials (P < .0001) and 21 times more likely to have a Clostridium difficile infection diagnosis (P < .0001). The most common probiotic formulations were Saccharomyces boulardii (32% of patients receiving probiotics), Lactobacillus acidophilus and Lactobacillus bulgaricus (30%), L acidophilus (28%), and Lactobacillus rhamnosus (11%). Probiotic use increased from 1.0% of 1,090,373 discharges in 2006 to 2.9% of 1,006,051 discharges in 2012 (P < .0001). CONCLUSIONS In this sample of U.S. hospitals, a sizable and growing number of inpatients received probiotics as part of their care despite inadequate evidence to support their use in this population. Additional research is needed to guide probiotic use in the hospital setting.

Medicare reimbursement attributable to catheter-associated urinary tract infection in the inpatient setting: a retrospective cohort analysis.

Background:Most catheter-associated urinary tract infections (CAUTIs) are considered preventable and thus a potential target for health care quality improvement and cost savings. Objectives:We sought to estimate excess Medicare reimbursement, length of stay, and inpatient death associated with CAUTI among hospitalized beneficiaries. Research Design:Using a retrospective cohort design with linked Medicare inpatient claims and National Healthcare Safety Network data from 2009, we compared Medicare reimbursement between Medicare beneficiaries with and without CAUTIs. Subjects:Fee-for-service Medicare beneficiaries aged 65 years or older with continuous coverage of parts A (hospital insurance) and B (supplementary medical insurance). Results:We found that beneficiaries with CAUTI had higher median Medicare reimbursement [intensive care unit (ICU):

Medicare Reimbursement Attributable to Periprosthetic Joint Infection Following Primary Hip and Knee Arthroplasty.

8548, non-ICU:

Sustained Infection Reduction in Outpatient Hemodialysis Centers Participating in a Collaborative Bloodstream Infection Prevention Effort.

1479) and length of stay (ICU: 8.1 d, non-ICU: 3.6 d) compared with those without CAUTI controlling for potential confounding factors. Odds of inpatient death were higher among beneficiaries with versus without CAUTI only among those with an ICU stay (ICU: odds ratio 1.37). Conclusions:Beneficiaries with CAUTI had increased Medicare reimbursement and length of stay compared with those without CAUTI after adjusting for potential confounders.

Duration of Antibiotic Use Among Adults With Uncomplicated Community-Acquired Pneumonia Requiring Hospitalization in the United States

This study estimated Medicare reimbursement attributable to periprosthetic joint infection (PJI) across the continuum of covered services four years following hip or knee arthroplasty. Using 2001-2008 Medicare claims data, total and annual attributable reimbursements were assessed using generalized linear regression, adjusting for potential confounders. Within one year following arthroplasty, 109 (1.04%) of 10,418 beneficiaries were diagnosed with PJI. Cumulative Medicare reimbursement in the PJI arm was 2.2-fold (1.9-2.6, P<.0001) or

Carbapenem-Nonsusceptible Acinetobacter baumannii, 8 US Metropolitan Areas, 2012-2015.

53,470 (

The projected burden of complex surgical site infections following hip and knee arthroplasties in adults in the United States, 2020 through 2030

39,575-

Reply to Dinh et al

68,221) higher than that of the non-PJI arm. The largest difference in reimbursement occurred the first year (3.2-fold); differences persisted the second (2.3-fold) and third (1.9-fold) follow up years. PJI following hip or knee arthroplasty appears costly to Medicare, with cost traversing several years and health care service areas.