Evaluation of the National Healthcare Safety Network standardized infection ratio risk adjustment for healthcare-facility-onset Clostridioides difficile infection in intensive care, oncology, and hematopoietic cell transplant units in general acute-care hospitals

AbstractObjective:To evaluate the National Health Safety Network (NHSN) hospital-onset Clostridioides difficile infection (HO-CDI) standardized infection ratio (SIR) risk adjustment for general acute-care hospitals with large numbers of intensive care unit (ICU), oncology unit, and hematopoietic cell transplant (HCT) patients.Design:Retrospective cohort study.Setting:Eight tertiary-care referral general hospitals in California.Methods:We used FY 2016 data and the published 2015 rebaseline NHSN HO-CDI SIR. We compared facility-wide inpatient HO-CDI events and SIRs, with and without ICU data, oncology and/or HCT unit data, and ICU bed adjustment.Results:For these hospitals, the median unmodified HO-CDI SIR was 1.24 (interquartile range [IQR], 1.15–1.34); 7 hospitals qualified for the highest ICU bed adjustment; 1 hospital received the second highest ICU bed adjustment; and all had oncology-HCT units with no additional adjustment per the NHSN. Removal of ICU data and the ICU bed adjustment decreased HO-CDI events (median, −25%; IQR, −20% to −29%) but increased the SIR at all hospitals (median, 104%; IQR, 90%–105%). Removal of oncology-HCT unit data decreased HO-CDI events (median, −15%; IQR, −14% to −21%) and decreased the SIR at all hospitals (median, −8%; IQR, −4% to −11%).Conclusions:For tertiary-care referral hospitals with specialized ICUs and a large number of ICU beds, the ICU bed adjustor functions as a global adjustment in the SIR calculation, accounting for the increased complexity of patients in ICUs and non-ICUs at these facilities. However, the SIR decrease with removal of oncology and HCT unit data, even with the ICU bed adjustment, suggests that an additional adjustment should be considered for oncology and HCT units within general hospitals, perhaps similar to what is done for ICU beds in the current SIR.

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Outcomes of pediatric oncology and hematopoietic cell transplant patients receiving extracorporeal membrane oxygenation

Perfusion ◽

10.1177/0267659119842471 ◽

2019 ◽

Vol 34 (7) ◽

pp. 598-604

Author(s):

Danielle K Maue ◽

Michael J Hobson ◽

Matthew L Friedman ◽

Elizabeth AS Moser ◽

Courtney M Rowan

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Extracorporeal Membrane Oxygenation ◽

Pediatric Intensive Care Unit ◽

Pediatric Intensive Care ◽

Hematopoietic Cell ◽

Cell Transplant ◽

Hematopoietic Cell Transplant ◽

Membrane Oxygenation ◽

Transplant Patients

Background/objectives: There is controversy regarding the utilization of extracorporeal membrane oxygenation in pediatric patients with an underlying oncologic diagnosis or who have undergone hematopoietic cell transplant. We hypothesized that these patients have higher mortality, more bleeding complications, more blood product utilization, and a higher rate of new infections than the general pediatric intensive care unit population supported with extracorporeal membrane oxygenation. Design/methods: This is a retrospective chart review at a single center quaternary care pediatric hospital including all pediatric intensive care unit extracorporeal membrane oxygenation patients from 2011 to 2016. Patients were categorized as either oncology/hematopoietic cell transplant or general pediatric intensive care unit. Patients from the cardiovascular intensive care unit or the neonatal intensive care unit were excluded. Results: A total of 38 patients met inclusion criteria of which 7 were oncology/hematopoietic cell transplant patients. The oncology/hematopoietic cell transplant group had lower platelets at the start of extracorporeal membrane oxygenation (p = 0.02) but other pre-extracorporeal membrane oxygenation characteristics were similar. Extracorporeal membrane oxygenation survival was lower in the oncology/hematopoietic cell transplant group (29% vs 77%, p = 0.02). The incidence of bleeding complications and new infections did not differ. The oncology/hematopoietic cell transplant group received more platelets (median of 15.9 mL/kg/day (interquartile range 8.4, 36.6) vs 7.9 mL/kg/day (3.3, 21.9), p = 0.04) and fresh frozen plasma (14.0 mL/kg/day (3, 15.7) vs 1.8 mL/kg/day (0.5, 5.9), p = 0.04). Conclusion: Oncology and hematopoietic cell transplant patients had a higher mortality and received more blood products while on extracorporeal membrane oxygenation than the general pediatric intensive care unit patients despite similar pre-extracorporeal membrane oxygenation characteristics. Physicians should use caution when deciding whether or not to utilize extracorporeal membrane oxygenation in this population.

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84. Evaluation of the NHSN Standardized Infection Ratio (SIR) Risk Adjustment for HO-CDI in Oncology and ICU Patients in General Acute Care Hospitals

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz359.008 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S4-S4

Author(s):

Christopher R Polage ◽

Kathleen A Quan ◽

Keith M Madey ◽

Frank Meyers ◽

Sneha Krishna ◽

...

Keyword(s):

Stem Cell ◽

Hematopoietic Stem Cell ◽

Acute Care ◽

Risk Adjustment ◽

Hematopoietic Stem Cell Transplant ◽

Stem Cell Transplant ◽

Cell Transplant ◽

General Hospitals ◽

Hematopoietic Stem ◽

Event Prediction

Abstract Background The NHSN healthcare-facility onset Clostridioides difficile infection (CDI) standardized infection ratio (SIR) is used to compare hospital quality and set hospital reimbursement but inadequate risk adjustment could penalize hospitals unnecessarily. We hypothesized that general hospitals with large oncology and/or ICU populations were not fully adjusted in the 2015 NHSN acute care hospital CDI Laboratory-Identified (LabID) event prediction model and SIRs would be affected. Methods We validated a negative binomial regression HO-CDI event prediction model identical to the 2015 published model and used FY2016 data from eight general hospitals in California to test our hypothesis. We compared HO-CDI events and SIR values, with and without oncology/hematopoietic stem cell transplant or ICU unit events, patient-days, admissions, bed counts, and adjustment parameters included. Results Seven major teaching and one nonteaching general acute care hospitals were included (see Table). Eight had oncology/hematopoietic stem cell transplant units; seven had ≥43 ICU beds (median: 134; interquartile range [IQR]: 84–161). The median facility unmodified FacWideIn SIR was 1.23 [IQR: 1.15, 1.29]. Removal of oncology unit data resulted in a 15% median facility decrease in HO-CDI events (IQR: 14%, 21%) and −8% median facility decrease in SIR (IQR: −2%, −14%). Removal of ICU unit data resulted in a 22% median facility decrease in HO-CDI events (IQR: 16%, 26%) and 97% median facility increase in SIR at each facility (IQR: 78%, 105%). Conclusion The ICU bed adjustment in the 2015 NHSN SIR is a powerful correction that fully adjusted for ICU HO-CDI events at all hospitals in the study. However, the lack of risk adjustment for oncology/hematopoietic stem cell transplant unit HO-CDI events suggests that the current model unfairly penalizes general acute facilities, many of which also provide specialized oncologic care. Thus, the model needs to be re-adjusted to account for this important specialty care population in general acute care facilities. Disclosures All Authors: No reported Disclosures.

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Allogeneic Hematopoietic Cell Transplant (HCT) Complications Requiring Transfer to the Intensive Care Unit (ICU) in a Medium Size Program

Transplantation and Cellular Therapy ◽

10.1016/s2666-6367(21)00479-6 ◽

2021 ◽

Vol 27 (3) ◽

pp. S372

Author(s):

Omar Elghawy ◽

John S. Wang ◽

Alexander C. Hafey ◽

Jessica Kassay-McAllister ◽

Hania Bushnaq-Aloul ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Hematopoietic Cell ◽

Medium Size ◽

Cell Transplant ◽

Hematopoietic Cell Transplant ◽

Allogeneic Hematopoietic Cell Transplant

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Effectiveness of bezlotoxumab for prevention of recurrent Clostridioides difficile infection among transplant recipients

Open Forum Infectious Diseases ◽

10.1093/ofid/ofab294 ◽

2021 ◽

Author(s):

Tanner M Johnson ◽

Amanda H Howard ◽

Matthew A Miller ◽

Lorna L Allen ◽

Misha Huang ◽

...

Keyword(s):

Organ Transplant ◽

Standard Of Care ◽

Hematopoietic Cell ◽

Solid Organ ◽

Cell Transplant ◽

Transplant Recipients ◽

Hematopoietic Cell Transplant ◽

Clostridioides Difficile ◽

Clostridioides Difficile Infection ◽

Solid Organ Transplant Recipients

Abstract Background Bezlotoxumab significantly reduces the incidence of recurrent Clostridioides difficile infection; however, limited data is available in solid-organ and hematopoietic-cell transplant recipients. Methods We conducted a single-center retrospective analysis comparing recurrent Clostridioides difficile infection in solid-organ and hematopoietic-cell transplant recipients receiving standard of care alone (oral vancomycin, fidaxomicin, or metronidazole) or bezlotoxumab plus standard of care. The primary outcome was 90-day incidence of recurrent Clostridioides difficile infection, and secondary outcomes included 90-day hospital readmission, mortality, and incidence of heart failure exacerbation. Results Overall, 94 patients received bezlotoxumab plus standard of care (n=38) or standard of care alone (n=56). The mean age was 53 years, patients had a median of 3 prior Clostridioides difficile episodes, and 4 risk factors for recurrent infection. Most patients were solid-organ transplant recipients (76%), with median time to index Clostridioides difficile infection occurring 2.7 years post-transplantation. Ninety-day recurrent Clostridioides difficile infection occurred in 16% (6/38) in the bezlotoxumab cohort compared to 29% (16/56) in the standard of care cohort (p=0.13). Multivariable regression revealed bezlotoxumab was associated with significantly lower odds of 90-day recurrent Clostridioides difficile infection (Odds Ratio [95% CI]: 0.28 [0.08-0.91]). There were no differences in secondary outcomes, and no heart failure exacerbations were observed. Conclusions In a cohort of primarily solid-organ transplant recipients, bezlotoxumab was well tolerated and associated with lower odds of recurrent Clostridioides difficile infection at 90-days. Larger, prospective trials are needed to confirm these findings amongst solid-organ and hematopoietic-cell transplant populations.

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Oral vancomycin for clostridioides difficile prophylaxis in allogenic hematopoietic cell transplant

Transplant Infectious Disease ◽

10.1111/tid.13790 ◽

2022 ◽

Author(s):

Olivia J. Altemeier ◽

Kelsey T. Konrardy

Keyword(s):

Hematopoietic Cell ◽

Cell Transplant ◽

Oral Vancomycin ◽

Hematopoietic Cell Transplant ◽

Clostridioides Difficile

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Impact of a Multiplexed Polymerase Chain Reaction Panel on Identifying Diarrheal Pathogens in Hematopoietic Cell Transplant Recipients

Clinical Infectious Diseases ◽

10.1093/cid/ciz1068 ◽

2019 ◽

Vol 71 (7) ◽

pp. 1693-1700 ◽

Cited By ~ 2

Author(s):

Wesley S Rogers ◽

Lars F Westblade ◽

Rosemary Soave ◽

Stephen G Jenkins ◽

Koen van Besien ◽

...

Keyword(s):

Polymerase Chain Reaction ◽

Hematopoietic Cell ◽

Cell Transplant ◽

Chain Reaction ◽

Hematopoietic Cell Transplant ◽

Clostridioides Difficile ◽

Multiplexed Pcr ◽

Clostridioides Difficile Infection ◽

Polymerase Chain ◽

The Impact

Abstract Background Diarrhea is common and associated with substantial morbidity among hematopoietic cell transplant (HCT) recipients, but the etiology is often not identified. Multiplexed polymerase chain reaction (PCR) assays increase the detection of diarrheal pathogens, but the impact of this technology in this population has not been evaluated. Methods Our center replaced stool cultures and other conventional microbiologic methods with the FilmArray Gastrointestinal Panel (GI PCR) in June 2016. We reviewed all adult patients who received an HCT from June 2014–May 2015 (pre–GI PCR, n = 163) and from June 2016–May 2017 (post–GI PCR, n = 182) and followed them for 1 year after transplantation. Clostridioides difficile infection was diagnosed by an independent PCR test in both cohorts. Results The proportion of patients with ≥1 identified infectious diarrheal pathogen increased from 25% to 37% after implementation of GI PCR (P = .01). Eight patients (5%) in the pre–GI PCR cohort tested positive for a pathogen other than C. difficile versus 49 patients (27%) in the post–GI PCR cohort (P < .001). The most common non–C. difficile diarrheal pathogens in the post–GI PCR cohort were enteropathogenic Escherichia coli (n = 14, 8%), norovirus (n = 14, 8%), and Yersinia enterocolitica (n = 7, 4%). The percentage of diarrheal episodes with an identified infectious etiology increased from 14% to 23% (P = .001). Median total costs of stool testing per patient did not increase (pre: $473; post: $425; P = .25). Conclusions Infectious etiologies of diarrhea were identified in a higher proportion of HCT recipients after replacing conventional stool testing with a multiplexed PCR assay, without an increase in testing costs.

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