Limiting the Emergence of Extended-Spectrumβ–Lactamase-Producing Enterobacteriaceae: Influence of Patient Population Characteristics on the Response to Antimicrobial Formulary Interventions

2006 ◽  
Vol 27 (3) ◽  
pp. 279-286 ◽  
Author(s):  
Adam D. Lipworth ◽  
Emily P. Hyle ◽  
Neil O. Fishman ◽  
Irving Nachamkin ◽  
Warren B. Bilker ◽  
...  
Keyword(s):  
Confidence Interval ◽  
Odds Ratio ◽  
Adjusted Odds Ratio ◽  
Medical Center ◽  
Academic Medical Center ◽  
Care Facility ◽  
Decubitus Ulcer ◽  
Population Characteristics ◽  
Term Care ◽  
Long Term Care Facility

Background.Effective methods to control the emergence of extended-spectrumβ-lactamase-producingEscherichia coliandKlebsiellaspecies (ESBL-EK) remain unclear. Variations in the patient populations at different hospitals may influence the effect of antimicrobial formulary interventions.Methods.To examine variations across hospitals in the response to antimicrobial interventions (ie, restriction of ceftazidime and ceftriaxone) designed to curb the spread of ESBL-EK, we conducted a 5-year quasi-experimental study. This study was conducted at 2 hospitals within the same health system: Hospital A is a 625-bed academic medical center, and Hospital B is a 344-bed urban community hospital. All adult patients with a healthcare-acquired clinical culture of ESBL-EK from July 1, 1997 through December 31, 2002 were included.Results.After the interventions, the use of ceftriaxone decreased by 86% at Hospital A and by 95% at Hospital B, whereas the use of ceftazidime decreased by 95% at Hospital A and by 97% at Hospital B. The prevalence of ESBL-EK at Hospital A decreased by 45% (P< .001), compared with a 22% decrease at Hospital B (P= .36). The following variables were significantly more common among ESBL-EK-infected patients at Hospital B: residence in a long-term care facility (adjusted odds ratio, 3.77 [95% confidence interval, 1.70-8.37]), advanced age (adjusted odds ratio, 1.04 [95% confidence interval, 1.01-1.06]), and presence of a decubitus ulcer (adjusted odds ratio, 4.13 [95% confidence interval, 1.97-8.65]).Conclusions.The effect of antimicrobial formulary interventions intended to curb emergence of ESBL-EK may differ substantially across institutions, perhaps as a result of differences in patient populations. Variability in the epidemiological profiles of ESBL-EK isolates at different hospitals must be considered when designing interventions to respond to these pathogens.

scholarly journals Anesthesiologist Specialization and Use of General Anesthesia for Cesarean Delivery

2019 ◽  
Vol 130 (2) ◽  
pp. 237-246 ◽  
Author(s):  
Benjamin T. Cobb ◽  
Meghan B. Lane-Fall ◽  
Richard C. Month ◽  
Onyi C. Onuoha ◽  
Sindhu K. Srinivas ◽  
...  
Keyword(s):  
General Anesthesia ◽  
Cesarean Delivery ◽  
Subgroup Analysis ◽  
Odds Ratio ◽  
Adjusted Odds Ratio ◽  
Medical Center ◽  
Academic Medical Center ◽  
Obstetric Anesthesia ◽  
Epidural Block ◽  
Cesarean Deliveries

AbstractEditor’s PerspectiveWhat We Already Know about This TopicWhat This Manuscript Tells Us That Is NewBackgroundGuidelines for obstetric anesthesia recommend neuraxial anesthesia (i.e., spinal or epidural block) for cesarean delivery in most patients. Little is known about the association of anesthesiologist specialization in obstetric anesthesia with a patient’s likelihood of receiving general anesthesia. The authors conducted a retrospective cohort study to compare utilization of general anesthesia for cesarean delivery among patients treated by generalist versus obstetric-specialized anesthesiologists.MethodsThe authors studied patients undergoing cesarean delivery for live singleton pregnancies from 2013 through 2017 at one academic medical center. Data were extracted from the electronic medical record. The authors estimated the association of anesthesiologist specialization in obstetric anesthesia with the odds of receiving general anesthesia for cesarean delivery.ResultsOf the cesarean deliveries in our sample, 2,649 of 4,052 (65.4%) were performed by obstetric-specialized anesthesiologists, and 1,403 of 4,052 (34.6%) by generalists. Use of general anesthesia differed for patients treated by specialists and generalists (7.3% vs. 12.1%; P &lt; 0.001). After adjustment, the odds of receiving general anesthesia were lower among patients treated by obstetric-specialized anesthesiologists among all patients (adjusted odds ratio, 0.71; 95% CI, 0.55 to 0.92; P = 0.011), and in a subgroup analysis restricted to urgent or emergent cesarean deliveries (adjusted odds ratio, 0.75; 95% CI, 0.56 to 0.99; P = 0.049). There was no association between provider specialization and the odds of receiving general anesthesia in a subgroup analysis restricted to evening or weekend deliveries (adjusted odds ratio, 0.76; 95% CI, 0.56 to 1.03; P = 0.085).ConclusionsTreatment by an obstetric anesthesiologist was associated with lower odds of receiving general anesthesia for cesarean delivery; however, this finding did not persist in a subgroup analysis restricted to evening and weekend deliveries.

Multiple Preoperative Endoscopic Retrograde Cholangiopancreatography and Large Common Bile Duct Diameter Predict the Need for Complex Surgery

2016 ◽  
Vol 82 (2) ◽  
pp. 122-127
Author(s):  
Holly Rochefort ◽  
Lea Matsuoka ◽  
Konstantinos Chouliaras ◽  
Didi Mwengela ◽  
James Buxbaum ◽  
...  
Keyword(s):  
Laparoscopic Cholecystectomy ◽  
Bile Duct ◽  
Common Bile Duct ◽  
Confidence Interval ◽  
Endoscopic Retrograde Cholangiopancreatography ◽  
Odds Ratio ◽  
Adjusted Odds Ratio ◽  
Academic Medical Center ◽  
Endoscopic Retrograde ◽  
Complex Surgery

Endoscopic retrograde cholangiopancreatography (ERCP) is frequently used to clear the common bile duct (CBD) in patients with choledocholithiasis. While a single ERCP is usually effective, many patients undergo multiple ERCP attempts before cholecystectomy. Here we sought to identify preoperative factors predictive of surgical complexity beyond routine laparoscopic cholecystectomy after ERCP. Data were prospectively collected for all ERCPs between September 2010 and February 2012 at a public academic medical center including demographics, indication, stone presence, CBD diameter, sphincterotomy, stent placement, and ERCP number. A total of 124 ERCPs were attempted in 73 patients with choledocholithiasis, 10 per cent of whom presented with cholangitis. Fifty-six per cent of patients underwent one ERCP, whereas 16 per cent required ≥ 3 procedures. Laparoscopic cholecystectomy was performed in 58 (79%) patients whereas 15 (21%) patients required more complex operations including eight open CBD explorations and two hepaticojejunostomies. The likelihood of requiring more complex surgery correlated with increasing number of ERCPs with an adjusted odds ratio of 5.75 (95% confidence interval: 2.31–14.3, P ≤ 0.001). Increased CBD diameter also correlated with complex surgery with adjusted odds ratio of 1.5 (95% confidence interval: 1.10–2.06, P = 0.012) for each millimeter. The number of pre-operative ERCPs and CBD diameter in choledocholithiasis patients are strong predictors of the need for open surgery and CBD exploration and should be considered in surgical planning and consent for patients requiring more than one ERCP procedure.

Importance of Bacterial Burden Among Methicillin-Resistant Staphylococcus aureus Carriers in a Long-Term Care Facility

2008 ◽  
Vol 29 (2) ◽  
pp. 143-148 ◽  
Author(s):  
Nimalie D. Stone ◽  
Donna R. Lewis ◽  
H. K. Lowery ◽  
Lyndsey A. Darrow ◽  
Catherine M. Kroll ◽  
...  
Keyword(s):  
Risk Factors ◽  
Odds Ratio ◽  
Nasal Swab ◽  
Long Term Care ◽  
Care Facility ◽  
Term Care ◽  
Long Term Care Facility ◽  
Culture Positive ◽  
Epidemiologic Characteristics

Objective.To evaluate the prevalence and transmission of methicillin-resistant Staphylococcus aureus (MRSA) nasal colonization, as well as risk factors associated with MRSA carriage, among residents of a long-term care facility (LTCF).Design.Prospective, longitudinal cohort study.Setting.A 100-bed Veterans Administration LTCFParticipants.All current and newly admitted residents of the LTCF during an 8-week study period.Methods.Nasal swab samples were obtained weekly and cultured on MRSA-selective media, and the cultures were graded for growth on a semiquantitative scale from 0 (no growth) to 6 (heavy growth). Epidemiologic data for the periods before and during the study were collected to assess risk factors for MRSA carriage.Results.Of 83 LTCF residents, 49 (59%) had 1 or more nasal swab cultures that were positive for MRSA; 34 (41%) were consistently culture-negative (designated “noncarriers”). Of the 49 culture-positive residents, 30 (36% of the total of 83 residents) had all cultures positive for MRSA (designated “persistent carriers”), and 19 (23% of the 83 residents) had at least 1 culture, but not all cultures, positive for MRSA (designated “intermittent carriers”). Multivariate analysis showed that participants with at least 1 nasal swab culture positive for MRSA were likely to have had previous hospitalization (odds ratio, 3.9) or wounds (odds ratio, 8.2). Persistent carriers and intermittent carriers did not differ in epidemiologic characteristics but did differ in mean MRSA growth score (3.7 vs 0.7; P < .001).Conclusions.Epidemiologic characteristics differed between noncarriers and subjects with at least 1 nasal swab culture positive for MRSA. However, in this LTCF population, only the degree of bacterial colonization (as reflected by mean MRSA growth score) distinguished persistent carriers from intermittent carriers. Understanding the burden of colonization may be important when determining future surveillance and control strategies.

scholarly journals 496. Carbapenem-resistant Enterobacter: A Case-Case–Control Investigation

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S242-S242
Author(s):  
Leore Cohen Mendel ◽  
David Katz ◽  
Tsilia Lazarovitch ◽  
Ronit Zaidenstein ◽  
Dror Marchaim
Keyword(s):  
Cox Regression ◽  
Clinical Epidemiology ◽  
Medical Center ◽  
Care Facility ◽  
Case Control ◽  
World Health ◽  
Term Care ◽  
Long Term Care Facility ◽  
Carbapenem Resistant ◽  
Matched Design

Abstract Background. Background The World Health Organization has declared carbapenem-resistant Enterobacteriaceae (CRE) as a worldwide public health threat. Analyzing the epidemiology of CRE was derived from cohorts consisting primarily of Klebsiella pneumoniae isolates. The second most frequent CRE is Enterobacter (CREn), but its molecular and clinical epidemiology differ from that of K. pneumoniae, and it has not been analyzed while implementing updated methodological tools and design. Methods A matched case-case–control investigation was conducted at Shamir (Assaf Harofeh) Medical Center, Israel, for calendar years 2007–2017. Each CREn case was matched to a carbapenem-susceptible Enterobacter (CSEn) case and to an uninfected control (1:1:1 ratio). Logistic and Cox regression-matched analyses were conducted in order to study predictors and outcomes of CREn colonization and/or infection, respectively. Results The study included 216 cases (72 in each group). Numerous predictors were significantly associated with CREn as per bivariable analyses, but the only independent significant predictors were: (1) recent (3 months) exposure to fluoroquinolones (aOR=2.94, P = 0.04), (2) intensive care unit stay in current hospitalization prior to culture (aOR=3.56, P = 0.003), and (3) a rapidly fatal McCabe score (aOR=0.471, P = 0.01). Patients with CREn suffered from significant delays in instituting appropriate antimicrobials (P = 0.03), and for those who survived the hospitalization, were more frequently discharged to a long-term care facility after being admitted to the index hospitalization from home (aOR=3.3, P = 0.02). Conclusion This case-case–control-matched investigation of CREn epidemiology, revealed a unique modifiable predictor, i.e., recent fluoroquinolone exposure, which could represent a target for stewardship intervention. The case-case–control-matched design allowed for the control of numerous confounders previously reported to be associated with CREn but may represent a risk factor for Enterobacter infection in general. As with other CRE, CREn carriers suffer from significant delays in initiation of appropriate antimicrobials and from worse outcomes. Disclosures All authors: No reported disclosures.

Clostridium difficile Infection in a Department of Veterans Affairs Long-Term Care Facility

2011 ◽  
Vol 32 (5) ◽  
pp. 513-515 ◽  
Author(s):  
Dubert M. Guerrero ◽  
Michelle M. Nerandzic ◽  
Lucy A. Jury ◽  
Shelley Chang ◽  
Robin L. Jump ◽  
...  
Keyword(s):  
Clostridium Difficile ◽  
Long Term Care ◽  
Medical Center ◽  
Care Facility ◽  
Healthcare Facility ◽  
Veterans Affairs ◽  
Term Care ◽  
Term Care Facility ◽  
Long Term Care Facility

In a Veterans Affairs medical center, 39% of healthcare facility–onset, healthcare facility-associated Clostridium difficile infections had their onset in the affiliated long-term care facility (LTCF). Eighty-five percent of LTCF-onset patients had been transferred from the hospital within the past month. Delays in diagnosis and treatment were common for LTCF-onset patients.

scholarly journals SAFETY SNACKS: IMPROVING QUALITY IN LONG-TERM CARE

2021 ◽  
pp. 24
Author(s):  
Keyword(s):  
Weight Loss ◽  
Odds Ratio ◽  
Long Term Care ◽  
Care Facility ◽  
Medium Effect ◽  
Term Care ◽  
Term Care Facility ◽  
Long Term Care Facility ◽  
Serious Injury

Falls among residents in the long-term care setting adversely affect resident health with potential for serious injury and quality of care provided. Nurses at the long-term care facility recognize the need to reduce falls. The nurses propose the intervention and name the initiative Safety Snacks. The research questions are: in a long-term care facility, does the practice of additional rounding while providing snacks twice daily, decrease the incidence of falls and falls with serious injury as compared to not providing Safety Snacks over a three-month period? Will unintended weight loss change by additional rounding during which nourishment and fluids are given to residents twice daily over a three-month period? The study examines the number of falls, falls with serious injury, and unintended weight loss before and after the Safety Snacks intervention. Poissons Means Test and odds ratio are used for fall data analysis. A two-proportion z-test is used for weight loss data. The results demonstrate a reduction in falls and falls with serious injury. The odds ratio demonstrates a medium effect in falls with serious injury. The two-proportion test on unintended weight loss yields a significant difference of 0.09 with a 95% confidence interval of (0.015, 0.17). One implication is the increase in rounding while providing nutrition and hydration may reduce falls and falls with serious injury. The second implication is the more significant effect on unintended weight loss with providing Safety Snacks. The third implication is the empowerment of nurses to recommend and execute a change in practice to improve quality.

Opioid underuse in terminal care of long-term care facility residents with pain and/or dyspnoea: A cross-sectional PACE-survey in six European countries

2020 ◽  
Vol 34 (6) ◽  
pp. 784-794 ◽  
Author(s):  
Marc Tanghe ◽  
Nele Van Den Noortgate ◽  
Luc Deliens ◽  
Tinne Smets ◽  
Bregje Onwuteaka-Philipsen ◽  
...  
Keyword(s):  
Confidence Interval ◽  
Terminal Care ◽  
Long Term Care ◽  
Care Facility ◽  
Term Care ◽  
Opioid Prescription ◽  
Term Care Facility ◽  
Long Term Care Facility ◽  
Care Facilities

Background/objectives: Opioids relieve symptoms in terminal care. We studied opioid underuse in long-term care facilities, defined as residents without opioid prescription despite pain and/or dyspnoea, 3 days prior to death. Design and setting: In a proportionally stratified randomly selected sample of long-term care facilities in six European Union countries, nurses and long-term care facility management completed structured after-death questionnaires within 3 months of residents’ death. Measurements: Nurses assessed pain/dyspnoea with Comfort Assessment in Dying with Dementia scale and checked opioid prescription by chart review. We estimated opioid underuse per country and per symptom and calculated associations of opioid underuse by multilevel, multivariable analysis. Results: Nurses’ response rate was 81.6%, 95.7% for managers. Of 901 deceased residents with pain/dyspnoea reported in the last week, 10.6% had dyspnoea, 34.4% had pain and 55.0% had both symptoms. Opioid underuse per country was 19.2% (95% confidence interval: 12.9–27.2) in the Netherlands, 25.2% (18.3–33.6) in Belgium, 29.3% (16.9–45.8) in England, 33.7% (26.2–42.2) in Finland, 64.6% (52.0–75.4) in Italy and 79.1% (71.2–85.3) in Poland ( p < 0.001). Opioid underuse was 57.2% (33.0–78.4) for dyspnoea, 41.2% (95% confidence interval: 21.9–63.8) for pain and 37.4% (19.4–59.6) for both symptoms ( p = 0.013). Odds of opioid underuse were lower (odds ratio: 0.33; 95% confidence interval: 0.20–0.54) when pain was assessed. Conclusion: Opioid underuse differs between countries. Pain and dyspnoea should be formally assessed at the end-of-life and taken into account in physicians orders.

scholarly journals Clinical and Demographic Characteristics of Patients With a New Diagnosis of Carriage or Clinical Infection With Carbapenemase-Producing Enterobacterales: A Retrospective Study

2021 ◽  
Vol 9 ◽  
Author(s):  
Assaf Adar ◽  
Hiba Zayyad ◽  
Maya Azrad ◽  
Kozita Libai ◽  
Ilana Aharon ◽  
...  
Keyword(s):  
Antibiotic Susceptibility ◽  
Medical Center ◽  
Resistance Mechanism ◽  
Care Facility ◽  
Control Measures ◽  
Clinical Infection ◽  
Term Care ◽  
Long Term Care Facility ◽  
Infection Control Measures ◽  
New Diagnosis

Background: To examine the clinical, demographic, and microbiologic characteristics of new rectal carbapenemase-producing carbapenem-resistant Enterobacterales (CP-CRE) carriers vs. those with a clinical infection, hospitalized at Padeh-Poriya Medical Center between 2014 and 2017 and to examine the susceptibility profiles of isolates from clinical infections.Methods: In this retrospective, chart analysis, demographic and clinical data were collected from medical charts of 175 adult patients with either new- onset carbapenemase-producing Enterobacterales (CPE) carriage or clinical CPE infection. Collected data included age, ethnic group, place of residence, hospitalizations in the past 90 days, and 30-day mortality. Microbiological analyses considered bacterial genus, molecular resistance mechanism and antibiotic susceptibility.Results: A significantly higher percentage (42.4%) of CPE carriers were long-term care facility residents, and had been recently hospitalized (56.3%), as compared to patients with clinical CPE infection (29.2 and 45.9%, respectively). Additionally, we noted a high (58.3%) acquision of CPE in our hospital. The most common bacterial isolate was K. pneumoniae and the most common resistance mechanism was Klebsiella pneumoniae (K. pneumoniae) carbapenemases (KPC). High susceptibility rates to amikacin and chloramphenicol were also noted.Conclusions: This study reaffirmed the importance of CPE screening and infection control measures. The observed antibiotic susceptibility profile suggests amikacin and chloramphenicol as potential treatments for CPE infection.

Changing Epidemiology of Community-Onset Methicillin-Resistant Staphylococcus aureus Bacteremia

2003 ◽  
Vol 24 (6) ◽  
pp. 431-435 ◽  
Author(s):  
Leonard B. Johnson ◽  
Arti Bhan ◽  
Joan Pawlak ◽  
Odette Manzor ◽  
Louis D. Saravolatz
Keyword(s):  
Risk Factors ◽  
Staphylococcus Aureus ◽  
Electric Fields ◽  
Medical Center ◽  
Academic Medical Center ◽  
Care Facility ◽  
Retrospective Case ◽  
Term Care ◽  
Methicillin Resistant ◽  
Community Onset

AbstractObjectives:To review cases of community-onset Staphylococcus aureus bacteremia and to evaluate whether the risk factors and epidemiology of methicillin-resistant S. aureus (MRSA) bacteremia have changed from early reports.Design:Retrospective case-comparison study of community-onset MRSA (n - 26) and methicillin-susceptible S. aureus (MSSA) (n = 26) bacteremias at our institution.Setting:A 600-bed urban academic medical center.Patients:Twenty-six patients with community-onset MRSA bacteremia were compared with 26 patients with community-onset MSSA bacteremia. Molecular analysis was performed on S. aureus isolates from the 26 MRSA cases as well as from 13 cases of community-onset S. aureus bacteremia from 1980 and 9 cases of nosocomial S. aureus bacteremia from 2001.Results:The two groups were similar except that patients with MRSA bacteremia were more likely to have presented from a long-term-care facility (26.9% vs 4%; P = .05) and to have had multiple admissions within the preceding year (46% vs 15%; P = .03). Clamped homogeneous electric fields analysis of MRSA isolates from 1982 revealed predominantly that one clone was the epidemic strain, whereas there were 14 unique strains among current community-onset isolates. Among current nosocomial isolates, 3 patterns were identified, all of which were present in the community-onset cases.Conclusions:Previously described risk factors for MRSA acquisition may not be helpful in predicting disease due to the polyclonal spread of MRSA in the community. Unlike early outbreaks of MRSA in patients presenting from the community, current acquisition appears to be polyclonal and is usually related to contact with the healthcare system.

Risk Factors for Colonization With Methicillin-ResistantStaphylococcus aureusin a Long-Term-Care Facility in Slovenia

2005 ◽  
Vol 26 (2) ◽  
pp. 191-195 ◽  
Author(s):  
Petra Vovko ◽  
Matjaz Retelj ◽  
Tjasa Zohar Cretnik ◽  
Borut Jutersek ◽  
Tatjana Harlander ◽  
...  
Keyword(s):  
Risk Factors ◽  
Odds Ratio ◽  
Long Term Care ◽  
Hospital Admissions ◽  
Care Facility ◽  
The Elderly ◽  
Term Care ◽  
Long Term Care Facility ◽  
Mrsa Colonization

AbstractObjective:To evaluate risk factors associated with methicillin-resistantStaphylococcus aureus(MRSA) colonization in a long-term-care facility (LTCF) for the elderly in Slovenia.Setting:A 351-bed community LTCF for the elderly.Design and Participants:This was a case-control study. MRSA carriage was identified in 102 of 127 residents of the facility's nursing unit. Two swabs were taken: one from the anterior nares and one from the largest skin lesion. If no skin lesions were present, the axillae and the groin area were swabbed. Data were collected regarding gender, age, length of stay in the facility, underlying conditions, functional status, presence of wounds or pressure sores, presence of catheters, antibiotic treatments, and hospital admissions.Results:We detected MRSA in 12 participants. Risk factors independently and significantly associated with MRSA colonization on the multivariate analysis were antibiotic treatments within 1 month before the investigation (odds ratio, 5.087; 95% confidence interval, 1.02 to 25.48;P= .048) and multiple hospital admissions in the 3 months before the investigation (odds ratio, 6.277; 95% confidence interval, 1.31 to 30.05;P= .022).Conclusions:This is the first assessment of risk factors for colonization with MRSA in an LTCF in Slovenia. MRSA poses a problem in this LTCF. Our observations may be valuable in implementing active surveillance cultures in infection control programs in Slovenian LTCFs.

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