scholarly journals 227. Epidemiology of bloodstream infections in Veterans Health Administration, 2010-2020

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S221-S222
Author(s):  
Aditya Sharma ◽  
Patricia Schirmer ◽  
Cynthia A Lucero-Obusan ◽  
Gina Oda ◽  
Mark Holodniy
Keyword(s):  
Positive Culture ◽  
Bloodstream Infections ◽  
Veterans Health Administration ◽  
Annual Incidence ◽  
Veterans Health ◽  
Health Administration ◽  
E Coli ◽  
Extended Spectrum ◽  
Healthcare Associated ◽  
Community Onset

Abstract Background National trends of bloodstream infections (BSI), their etiologies, and prevalence of resistance are not well described. We reviewed BSI during 2010-2020 in the Veterans Health Administration (VHA), the largest healthcare system in the United States. Methods Demographic, microbiological, and healthcare exposure data were extracted from VHA databases. A case was defined as isolation of a microbe from blood specimens collected from a hospitalized person; common commensals required matching organisms isolated within two consecutive days. The first organism-specific episode within a 14-day period was counted. Staphylococcus, Enterococcus, S. pneumoniae, and gram-negative isolates were assessed for resistance to methicillin, vancomycin, any antimicrobial, and extended-spectrum cephalosporins or carbapenems, respectively. Cases were classified as community acquired (CA-), healthcare-associated community onset (HCO-), and hospital onset (HO-). Trends were estimated by generalized linear mixed models. Results During 2010-2020, incidence of CA-BSI decreased from 42.2 to 27.6 per 100,000 users, HCO-BSI decreased from 63.7 to 40.7 per 100,000 users, and HO-BSI decreased from 28.2 to 16.4 per 100,000 users (Figure 1A). S. aureus and E. coli were the most common in CA-BSI and HCO-BSI; S. aureus and Enterococcus were the most common in HO-BSI; the prevalence of E. coli increased in BSI across classifications (Figure 1B). Incidence of BSI caused by resistant Pseudomonadales and Enterococcus decreased by more than 15% annually; annual incidence of BSI caused by other organisms decreased by less than 10% or remained unchanged with the exception of extended-spectrum cephalosporin resistant E. coli, which increased 6% annually (Figure 2). HO-BSI were more resistant than CA-BSI and HCO-BSI across organisms; resistance among E. coli and S. pneumoniae BSI increased across classifications (Figure 3). Figure 1. Trends of bloodstream infections by organism in Veterans Health Administration, 2010-2020. (A) Incidence per 100,000 users. (B) Percentage of incident BSI by organism. Trends are adjusted for distributions of age, gender, and number of users, in addition to accounting for clustering by county and facility. Community acquired: positive culture collected less than 4 days after hospitalization from a person without previous healthcare exposures. Healthcare-associated community onset: positive culture collected less than 4 days after hospitalization from a person with previous healthcare exposures. Hospital onset: positive culture collected 4 or more days after hospitalization. Figure 2. Percentage change in annual incidence of bloodstream infections by organism in Veterans Health Administration, 2010-2020. Dots represent point estimates and horizontal bars represent 95% confidence intervals. Figure 3. Trends in prevalence of resistance among organisms causing bloodstream infection by epidemiological classification in Veterans Health Administration, 2010-2020 Trends are adjusted for distributions of age, gender, and number of users, in addition to accounting for clustering by county and facility. Community acquired: positive culture collected less than 4 days after hospitalization from a person without previous healthcare exposures. Healthcare-associated community onset: positive culture collected less than 4 days after hospitalization from a person with previous healthcare exposures. Hospital onset: positive culture collected 4 or more days after hospitalization. Conclusion BSI incidence decreased during 2010-2020 across classifications. CO-BSI and HCO-BSI occurred more frequently and were less resistant than HO-BSI. S. pneumoniae and E. coli BSIs became more resistant over time. Increasing incidence of BSI caused by E. coli resistant to extended-spectrum cephalosporins warrants urgent investigation. Disclosures All Authors: No reported disclosures

scholarly journals 1164. County-Level Geographic Distribution of Extended-Spectrum Cephalosporin-Resistant Enterobacteriaceae Across Outpatient Settings of the Veterans Health Administration, 2000–2017

2018 ◽  
Vol 5 (suppl_1) ◽  
pp. S350-S351
Author(s):  
Michihiko Goto ◽  
Rajeshwari Nair ◽  
Daniel Livorsi ◽  
Marin Schweizer ◽  
Michael Ohl ◽  
...  
Keyword(s):  
United States ◽  
Veterans Health Administration ◽  
The United States ◽  
Incidence Rates ◽  
County Level ◽  
Veterans Health ◽  
Health Administration ◽  
Geographic Variability ◽  
Extended Spectrum ◽  
Outpatient Settings

Abstract Background Extended-spectrum cephalosporin resistance (ESCR) among Enterobacteriaceae has emerged globally over the last two decades, with increased prevalence in the community. Data from European countries and healthcare-associated isolates in the United States have demonstrated substantial geographic variability in the prevalence of ESCR, but community-onset isolates in the United States have been less studied. We aimed to describe geographic distribution and spread of ESCR among outpatient settings across the Veterans Health Administration (VHA) over 18 years. Methods We analyzed a retrospective cohort of all patients who had any positive clinical culture specimen for ESCR Enterobacteriaceae collected in an outpatient setting; ESCR was defined by phenotypic nonsusceptibility to at least one extended-spectrum cephalosporin agent or detection of an extended-spectrum β-lactamase. Patient-level data were grouped by county of residence, and the total number of unique patients who received care within VHA for each county was used as a denominator. We aggregated data by time terciles (2000–2005, 2006–2011, and 2012–2017), and overall and county-level incidence rates were calculated as the number of unique patients in each year with ESCR Enterobacteriaceae per person-year. Results During the study period, there were 1,980,095 positive cultures for Enterobacteriaceae from 870,797 unique patients across outpatient settings of VHA, from a total of 107,404,504 person-years. Among those, 136,185 cultures (6.9%) from 75,500 unique patients (8.7%) were ESCR. The overall incidence rate was 9.0 cases per 10,000 person-years, which increased from 6.3 per 10,000 person-years in 2000 to 14.6 per 10,000 person-years in 2017. County-level incidence rates ranged widely but increased overall (interquartile range [IQR] in 2000–2005: 0–6.7; 2006–2011: 0–9.1; 2012–2017: 3.1–14.3 per 10,000 person-years), with some geographic clustering (figure). Conclusion This study demonstrates that there has been geographic variation both in incidence rates and trends of ESCR Enterobacteriaceae in outpatient settings of VHA, which suggests the importance of tailoring local antibiotic-prescribing guidelines incorporating geographic variability in epidemiology. Disclosures M. Ohl, Gilead Sciences, Inc.: Grant Investigator, Research grant.

scholarly journals Shift to community-onset Clostridium difficile infection in the national Veterans Health Administration, 2003-2014

2018 ◽  
Vol 46 (4) ◽  
pp. 431-435 ◽  
Author(s):  
Kelly R. Reveles ◽  
Mary Jo V. Pugh ◽  
Kenneth A. Lawson ◽  
Eric M. Mortensen ◽  
Jim M. Koeller ◽  
...  
Keyword(s):  
Clostridium Difficile ◽  
Clostridium Difficile Infection ◽  
Veterans Health Administration ◽  
Veterans Health ◽  
Health Administration ◽  
Community Onset

scholarly journals Extended-Spectrum-β-Lactamase- and Plasmid AmpC-Producing Escherichia coli Causing Community-Onset Bloodstream Infection: Association of Bacterial Clones and Virulence Genes with Septic Shock, Source of Infection, and Recurrence

2020 ◽  
Vol 64 (8) ◽  
Author(s):  
Inga Fröding ◽  
Badrul Hasan ◽  
Isak Sylvin ◽  
Maarten Coorens ◽  
Pontus Nauclér ◽  
...  
Keyword(s):  
Escherichia Coli ◽  
Septic Shock ◽  
Prostate Biopsy ◽  
Virulence Genes ◽  
Multivariable Analysis ◽  
Bloodstream Infections ◽  
Content Type ◽  
E Coli ◽  
Extended Spectrum ◽  
Community Onset

ABSTRACT Invasive infections due to extended-spectrum-β-lactamase- and pAmpC-producing Escherichia coli (ESBL/pAmpC-EC) are an important cause of morbidity, often caused by the high-risk clone sequence type (ST131) and isolates classified as extraintestinal pathogenic E. coli (ExPEC). The relative influence of host immunocompetence versus microbiological virulence factors in the acquisition and outcome of bloodstream infections (BSI) is poorly understood. Herein, we used whole-genome sequencing on 278 blood culture isolates of ESBL/pAmpC-EC from 260 patients with community-onset BSI collected from 2012 to 2015 in Stockholm to study the association of virulence genes, sequence types, and antimicrobial resistance with severity of disease, infection source, ESBL/pAmpC-EC BSI low-risk patients, and patients with repeated episodes. ST131 subclade C2 comprised 29% of all patients. Factors associated with septic shock in multivariable analysis were patient host factors (hematologic cancer or transplantation and reduced daily living activity), presence of the E. coli virulence factor iss (increased serum survival), absence of phenotypic multidrug resistance, and absence of the genes pap and hsp. Adhesins, particularly pap, were associated with urinary tract infection (UTI) source, while isolates from post-prostate biopsy sepsis had a low overall number of virulence operons, including adhesins, and commonly belonged to ST131 clades A, B, and subclade C1, ST1193, and ST648. ST131 was associated with recurrent episodes. In conclusion, the most interesting finding is the association of iss with septic shock. Adhesins are important for UTI pathogenesis, while otherwise low-pathogenic isolates from the microbiota can cause post-prostate biopsy sepsis.

Denominator Doesn’t Matter: Standardizing Healthcare-Associated Infection Rates by Bed Days or Device Days

2015 ◽  
Vol 36 (6) ◽  
pp. 710-716 ◽  
Author(s):  
Molly J. Horstman ◽  
Yu-Fang Li ◽  
Peter L. Almenoff ◽  
Ron W. Freyberg ◽  
Barbara W. Trautner
Keyword(s):  
Veterans Health Administration ◽  
Strongly Correlated ◽  
Veterans Health ◽  
Health Administration ◽  
Infection Rates ◽  
Healthcare Associated Infection ◽  
Administration Medical ◽  
Medical Centers ◽  
Bed Days ◽  
Healthcare Associated

OBJECTIVETo examine the impact on infection rates and hospital rank for catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI), and ventilator-associated pneumonia (VAP) using device days and bed days as the denominatorDESIGNRetrospective survey from October 2010 to July 2013SETTINGVeterans Health Administration medical centers providing acute medical and surgical carePATIENTSPatients admitted to 120 Veterans Health Administration medical centers reporting healthcare-associated infectionsMETHODSWe examined the importance of using device days and bed days as the denominator between infection rates and hospital rank for CAUTI, CLABSI, and VAP for each medical center. The relationship between device days and bed days as the denominator was assessed using a Pearson correlation, and changes in infection rates and device utilization were evaluated by an analysis of variance.RESULTSA total of 7.9 million bed days were included. From 2011 to 2013, CAUTI decreased whether measured by device days (2.32 to 1.64, P=.001) or bed days (4.21 to 3.02, P=.006). CLABSI decreased when measured by bed days (1.67 to 1.19, P=.04). VAP rates and device utilization ratios for CAUTI, CLABSI, and VAP were not statistically different across time. Infection rates calculated with device days were strongly correlated with infection rates calculated with bed days (r=0.79–0.94, P<.001). Hospital relative performance measured by ordered rank was also strongly correlated for both denominators (r=0.82–0.96, P<.001).CONCLUSIONSThese findings suggest that device days and bed days are equally effective adjustment metrics for comparing healthcare-associated infection rates between hospitals in the setting of stable device utilization.Infect Control Hosp Epidemiol 2015;00(0): 1–7

scholarly journals Excess Length of Acute Inpatient Stay Attributable to Acquisition of Hospital-Onset Gram-Negative Bloodstream Infection with and without Antibiotic Resistance: A Multistate Model Analysis

Antibiotics ◽  
2020 ◽  
Vol 9 (2) ◽  
pp. 96 ◽  
Author(s):  
Hiroyuki Suzuki ◽  
Eli N Perencevich ◽  
Rajeshwari Nair ◽  
Daniel J Livorsi ◽  
Michihiko Goto
Keyword(s):  
Veterans Health Administration ◽  
Business Case ◽  
Inpatient Stay ◽  
Veterans Health ◽  
Health Administration ◽  
Multistate Models ◽  
Multistate Model ◽  
Administration System ◽  
E Coli ◽  
Klebsiella Spp

Excess length of stay (LOS) is an important outcome when assessing the burden of nosocomial infection, but it can be subject to survival bias. We aimed to estimate the change in LOS attributable to hospital-onset (HO) Escherichia coli/Klebsiella spp. bacteremia using multistate models to circumvent survival bias. We analyzed a cohort of all patients with HO E. coli/Klebsiella spp. bacteremia and matched uninfected control patients within the U.S. Veterans Health Administration System in 2003–2013. A multistate model was used to estimate the change in LOS as an effect of the intermediate state (HO-bacteremia). We stratified analyses by susceptibilities to fluoroquinolones (fluoroquinolone susceptible (FQ-S)/fluoroquinolone resistant (FQ-R)) and extended-spectrum cephalosporins (ESC susceptible (ESC-S)/ESC resistant (ESC-R)). Among the 5964 patients with HO bacteremia analyzed, 957 (16.9%) and 1638 (28.9%) patients had organisms resistant to FQ and ESC, respectively. Any HO E.coli/Klebsiella bacteremia was associated with excess LOS, and both FQ-R and ESC-R were associated with a longer LOS than susceptible strains, but the additional burdens attributable to resistance were small compared to HO bacteremia itself (FQ-S: 12.13 days vs. FQ-R: 12.94 days, difference: 0.81 days (95% CI: 0.56–1.05), p < 0.001 and ESC-S: 11.57 days vs. ESC-R: 16.56 days, difference: 4.99 days (95% CI: 4.75–5.24), p < 0.001). Accurate measurements of excess attributable LOS associated with resistance can help support the business case for infection control interventions.

scholarly journals Modified Veterans Health Administration Clostridioides difficile Infection (CDI) Prevention Bundle: Progress Over 8 Years Decreasing CDI Laboratory-Identified (LabID) Events at a Large Veterans Affairs Medical Center

2020 ◽  
Vol 41 (S1) ◽  
pp. s319-s319
Author(s):  
Patricia Byers ◽  
Andrew Hunter ◽  
Edward J. Young ◽  
Sherri-Lynne Almeida ◽  
Karen Stonecypher ◽  
...  
Keyword(s):  
Hand Hygiene ◽  
Antimicrobial Stewardship ◽  
Veterans Health Administration ◽  
Team Approach ◽  
Veterans Health ◽  
Case Review ◽  
Health Administration ◽  
Care Providers ◽  
Core Measures ◽  
Community Onset

Background: In March 2012, the Veterans’ Health Administration (VHA) published the Guideline for the Prevention of Clostridium difficile infection (CDI) in VHA Inpatient Acute-Care Facilities, with a goal of 30% reduction of cases within 2 years. In March 2011, this facility, along with 31 others, served as a pilot site to develop the guidelines. Methods: The CDI prevention bundle was implemented to prevent new onset CDI cases in the facility with 4 core measures: (1) environmental cleaning (EMS), (2) hand hygiene, (3) contact precautions, and (4) cultural transformation. Education was provided to EMS staff, nursing, and care providers on the CDI case definition, criteria for testing, empiric isolation for patients with diarrhea, hand hygiene, and PPE to control spread. In 2014, antimicrobial stewardship was added, and within 5 years an algorithm for isolation and testing was published. Cases were reviewed weekly using TheraDoc software and were reported monthly to the national VHA Inpatient Evaluation Center (IPEC). Isolation was communicated using a ward roster/isolation list in TheraDoc for all unit champions to consult daily. CDI cases were classified using NHSN definitions for a laboratory-identified (LabID) event, recurrent cases, and community-onset cases. Real-time case review and weekly multidisciplinary case discussions identified opportunities for improved compliance with the core measures. Results: Over an 8-year period, CDI healthcare-onset LabID events decreased by 73%. The cases decreased from 149 to 40 over the 8-year period. The infection rate decreased 70% from 16.19 per 10,000 bed days of care in FY2011 (October 2010) to 4.88 in FY2019. The incidence of community onset infections increased from 75 in FY2011 to a high of 146 in FY2018 for a rate of 8.15 to 18.17. In FY2019, there was a decrease in both LabID events and community-onset cases to lows of 40 and 102, respectively. Inappropriate testing decreased by 84% from 50 in FY2011 to 8 in FY2019. Conclusions: A multidisciplinary team approach that included support from leadership and clinical providers as well as front line staff involvement, daily rounding, and case review by infection preventionists has reduced all CDI cases over an 8-year period using the modified VHA CDI bundle. TheraDoc enabled case review, correct isolation, changes to cleaning practices, and more appropriate lab testing. The antimicrobial stewardship program that includes clinical pharmacists working daily with providers was a strong driver for change.Funding: NoneDisclosures: None

scholarly journals 1052. Do Healthcare Providers De-Escalate β-Lactam (BL) Antibiotic Therapy Based on Results of Antibiotic Susceptibility Testing (AST)? Analysis of Bloodstream Infections (BSI) Caused by Escherichia coli and Klebsiella pneumoniae From the Veterans Health Administration (VHA)

2018 ◽  
Vol 5 (suppl_1) ◽  
pp. S314-S315
Author(s):  
Roberto Viau ◽  
Brigid Wilson ◽  
Scott R Evans ◽  
Federico Perez ◽  
Vance G Fowler ◽  
...  
Keyword(s):  
Escherichia Coli ◽  
Klebsiella Pneumoniae ◽  
Mayo Clinic ◽  
Active Agent ◽  
Bloodstream Infections ◽  
Veterans Health ◽  
Health Administration ◽  
E Coli ◽  
Optimal Therapy ◽  
Research Grant

Abstract Background Achieving appropriate therapy for BSI caused by Gram-negative rods (GNR) is challenging. The availability of AST results allows de-escalation from broad- to narrow-spectrum agents. De-escalation is a goal of antimicrobial stewardship (AS). Through the analysis of inpatient BL antibiotic regimens in a nationwide cohort of patients with Escherichia coli and Klebsiella pneumoniae BSI, we compared the relative spectrum of empiric and definitive treatments to AST results and identified opportunities for de-escalation. Methods Using a cohort of patients hospitalized within VHA, we identified patients with a blood culture positive for E. coli or K. pneumoniae between 2006 and 2015. We analyzed the subset of patients receiving inpatient BLs before and after Gram stain (GS) and AST results. BLs were grouped into five tiers of increasing spectrum, both with and without a requirement for anaerobic activity (Figure 1). Tiers of BLs across the treatment periods were summarized and compared with the lowest-spectrum tier with an active agent. Rates of inactive, optimal, and overly broad BL therapy were summarized by organism and treatment period. Results Of 36,531 BSI identified, we analyzed a subset of 10,825 (7,100 E. coli, 3,725 K. pneumoniae) that met our inclusion criteria (Figure 2). The use of inactive BL agents decreased across time, falling from 11% in early empiric to 4.5% in definitive treatments. The proportion of patients receiving the narrowest available effective BL therapy (“optimal” therapy) increased from 5% to 8% after GS results and to 14% after AST results (Figure 3). De-escalation to optimal therapy after AST results was observed in only 7% of opportunities. If anaerobic activity was required, a smaller proportion of cases would be considered overtreated in the empiric periods (45–46%), but de-escalation after AST results was observed in only 10% of these cases. Conclusion Changes in BL agents across treatment periods reflect an escalation to active treatment, but the absence of de-escalation after AST results was available. This was true both with and without considering a need for anaerobic activity. Expansion of this analysis to include additional classes such as fluoroquinolones may reveal opportunities for AS and de-escalation to optimal therapy in the treatment of E. coli and K. pneumoniae BSI. Disclosures R. Patel, CD Diagnostics, BioFire, Curetis, Merck, Hutchison Biofilm Medical Solutions, Accelerate Diagnostics, Allergan, and The Medicines Company: Grant Investigator, Research grant – monies paid to Mayo Clinic. Curetis, Specific Technologies, Selux Dx, GenMark Diagnostics, PathoQuest and Genentech: Consultant and Scientific Advisor, Consulting fee – monies paid to Mayo Clinic. ASM and IDSA: Travel reimbursement and editor’s stipends, Travel reimbursement and editor’s stipends. NBME, Up-to-Date and the Infectious Diseases Board Review Course: Varies, Honoraria. Mayo Clinic: Employee, Salary. R. Banerjee, Accelerate Diagnostics, Biomerieux, BioFire: Grant Investigator, Research grant and Research support.

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