2012. Trends in Microbiological Culture Collection Across Veterans Affairs Medical Centers and Community Living Centers, 2010 to 2017

Abstract Background Microbiological cultures are critical in the diagnosis of infection, identification of pathogenic organisms, and tailoring antibiotic use. However, unnecessary collection of cultures, particularly from the urine, may lead to overuse of antibiotics. There have been no national studies to evaluate trends in the collection of cultures in acute and long-term care settings. Here we describe changes in the collection of cultures nationally across Veterans Affairs medical centers (VAMCs) and Community Living Centers (CLCs). Methods All positive and negative cultures collected from 2010 to 2017 among Veterans admitted to VAMCs or CLCs were included. Cultures were categorized by specimen source (urine, blood, skin and soft tissue, or lung). Joinpoint software was used for regression analyses of trends over time and to estimate annual average percent changes with 95% confidence intervals (CI). Results A total of 5,089,640 cultures from 158 VAMCS and 342,850 cultures from 146 CLCs were identified. The number of cultures collected for all culture types in VAMCs and CLCs decreased significantly. The number of cultures collected per admission decreased significantly by 5.5% annually among VAMCs (95% CI −7.0 to −4.0%) and by 8.4% annually among CLCs (95% CI −10.1 to −6.6%). The proportion of positive cultures decreased 1.6% annually among VAMCs (95% CI −2.3 to −0.9%) and remained stable among CLCs (-0.4% annually, 95% CI, −1.1 to 0.4%). The most common culture source among VAMCs was blood (36.2%), followed by urine (31.8%), and among CLCs was urine (56.9%), followed by blood (16.0%). Urine cultures decreased by 4.5% annually among VAMCs (95% CI −5.4 to −3.6%) and 7.0% annually among CLCs (95% CI −7.6 to −6.4%). Conclusion Our study demonstrates a significant reduction in the number of cultures collected over time. Positive cultures decreased significantly in VAMCs, possibly indicating fewer culture-positive infections.In both VAMCs and CLCs, decreases in cultures taken may represent an important reduction in the collection of unnecessary cultures nationally driven by increased awareness about over-testing and over-treatment of presumed infection, particularly urinary tract infections. Disclosures All authors: No reported disclosures.

Download Full-text

Changes in antibiotic use following implementation of a telehealth stewardship pilot program

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2019.128 ◽

2019 ◽

Vol 40 (7) ◽

pp. 810-814 ◽

Cited By ~ 2

Author(s):

Brigid M. Wilson ◽

Richard E. Banks ◽

Christopher J. Crnich ◽

Emma Ide ◽

Roberto A. Viau ◽

...

Keyword(s):

Antibiotic Stewardship ◽

Long Term Care ◽

Antibiotic Use ◽

Veterans Affairs ◽

Term Care ◽

Medical Centers ◽

Stewardship Program ◽

Days Of Therapy ◽

Veterans Affairs Medical Centers

AbstractStarting in 2016, we initiated a pilot tele-antibiotic stewardship program at 2 rural Veterans Affairs medical centers (VAMCs). Antibiotic days of therapy decreased significantly (P < .05) in the acute and long-term care units at both intervention sites, suggesting that tele-stewardship can effectively support antibiotic stewardship practices in rural VAMCs.

Download Full-text

National trends in the treatment of urinary tract infections among Veterans’ Affairs Community Living Center residents

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2019.204 ◽

2019 ◽

Vol 40 (10) ◽

pp. 1087-1093 ◽

Cited By ~ 3

Author(s):

Haley J. Appaneal ◽

Aisling R. Caffrey ◽

Vrishali V. Lopes ◽

Christopher J. Crnich ◽

David M. Dosa ◽

...

Keyword(s):

Urinary Tract ◽

Antibiotic Use ◽

Veterans Affairs ◽

Community Living ◽

Days Of Therapy ◽

Community Living Centers ◽

Tract Infections ◽

National Trends ◽

Culture Positive ◽

Culture Negative

AbstractObjective:To describe urinary tract infection (UTI) treatment among Veterans’ Affairs (VA) Community Living Centers (CLCs) nationally and to assess related trends in antibiotic use.Design:Descriptive study.Setting and participants:All UTI episodes treated from 2013 through 2017 among residents in 110 VA CLCs. UTI episodes required collection of a urine culture, antibiotic treatment, and a UTI diagnosis code. UTI episodes were stratified into culture-positive and culture-negative episodes.Methods:Frequency and rate of antibiotic use were assessed for all UTI episodes overall and were stratified by culture-positive and culture-negative episodes. Joinpoint software was used for regression analyses of trends over time.Results:We identified 28,247 UTI episodes in 14,983 Veterans. The average age of Veterans was 75.7 years, and 95.9% were male. Approximately half of UTI episodes (45.7%) were culture positive and 25.7% were culture negative. Escherichia coli was recovered in 34.1% of culture-positive UTI episodes, followed by Proteus mirabilis and Klebsiella spp, which were recovered in 24.5% and 17.4% of culture-positive UTI episodes, respectively. The rate of total antibiotic use in days of therapy (DOT) per 1,000 bed days decreased by 10.1% per year (95% CI, −13.6% to −6.5%) and fluoroquinolone use (ciprofloxacin or levofloxacin) decreased by 14.5% per year (95% CI, −20.6% to −7.8%) among UTI episodes overall. Similar reductions in rates of total antibiotic use and fluoroquinolone use were observed among culture-positive UTI episodes and among culture-negative UTI episodes.Conclusion:Over a 5-year period, antibiotic use for UTIs significantly decreased among VA CLCs, as did use of fluoroquinolones. Antibiotic stewardship efforts across VA CLCs should be applauded, and these efforts should continue.

Download Full-text

Implementation of an Antibiotic Timeout at Veterans’ Affairs Medical Centers (VAMC): COVID-19 Facilitators and Barriers

Antimicrobial Stewardship & Healthcare Epidemiology ◽

10.1017/ash.2021.7 ◽

2021 ◽

Vol 1 (S1) ◽

pp. s3-s3

Author(s):

Jorie Butler ◽

Joshua Judd ◽

Cassie Goedken ◽

Vanessa Stevens ◽

Nui Brown ◽

...

Keyword(s):

Implementation Process ◽

High Volume ◽

Antibiotic Use ◽

Multidrug Resistant ◽

Veterans Affairs ◽

Record System ◽

Medical Centers ◽

Facilitators And Barriers ◽

Veterans Affairs Medical Centers ◽

The Impact

Effective stewardship strategies such as an “antibiotic timeout” to encourage prescriber reflection on the use of broad-spectrum antibiotics are critical to reduce the threat of multidrug-resistant organisms. We sought to understand the facilitators and barriers of the implementation of the Antibiotic Self-Stewardship Timeout Program (SSTOP), which used a template note integrated into the electronic health record system to guide decision making regarding anti- methicillin-resistant S. aureus (MRSA) therapy after 3 days of hospitalization. We conducted interviews at 10 Veterans’ Affairs medical centers (VAMCs) during the preimplementation period (N = 16 antibiotic stewards) and postimplementation (N = 13 antibiotic stewards) ~12 months after program initiation. Preimplementation interviews focused on current stewardship programs, whereas postimplementation interviews addressed the implementation process and corresponding challenges. We also directly asked about the impact of COVID-19 on stewardship activities at each facility. Interviews were transcribed and analyzed using consensus-based inductive and deductive coding. Codes were iteratively combined into barrier and facilitator groupings. Barriers identified in the preimplementation interviews included challenges with staffing, the difficulties of changing prescribing culture, and academic affiliates (eg, rotating physician trainees). Facilitators included intellectual support (eg, providers who understand the concept of stewardship), facility support, individual strengths of antibiotic stewards (eg, diplomacy, strong relationships with surgeons), and resources such as VA policies mandating stewardship. By the postimplementation phase, all sites reported a high volume of COVID-19 cases. Additional demands were placed on infectious disease providers who comprise the antibiotic stewardship teams, which complicated the implementation of SSTOP. Many barriers and facilitators mentioned were similar to those identified during preimplementation interviews. Staffing problems and specific providers not “getting it [stewardship activities]” continued, whereas facilitators centered around strong institutional support. Specific pandemic-related barriers included slow down or stoppage of stewardship activities including curbing of regular MRSA screening practices, halting weekly stewardship rounds, and delaying stewardship committee planning. Pandemic-specific staffing problems occurred due to the need for “all hands on deck” and challenges with staff working from home, as well as being pulled in multiple directions, (eg, writing COVID-19 policies). Furthermore, an increase in antibiotic use was also reported at sites during COVID-19 surges. Our findings indicate that SSTOP implementation met with barriers at most times; however, pandemic-specific barriers were particularly powerful. Sites with strong staffing resources were better equipped to deal with these challenges. Understanding how the program evolves with subsequent COVID-19 surges will be important to support the broad implementation of SSTOP.Funding: NoDisclosures: None

Download Full-text

Epidemiology and clinical outcomes associated with extensively drug-resistant (XDR) Acinetobacter in US Veterans’ Affairs (VA) medical centers

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.450 ◽

2020 ◽

pp. 1-6

Author(s):

Margaret A. Fitzpatrick ◽

Katie J. Suda ◽

Linda Poggensee ◽

Amanda Vivo ◽

Marissa Wirth ◽

...

Keyword(s):

Acinetobacter Baumannii ◽

Clinical Outcomes ◽

Treatment Options ◽

Patient Characteristics ◽

Veterans Affairs ◽

Drug Resistant ◽

Term Care ◽

Medical Centers ◽

Extensively Drug Resistant ◽

Veterans Affairs Medical Centers

Abstract Objective: Although infections caused by Acinetobacter baumannii are often healthcare-acquired, difficult to treat, and associated with high mortality, epidemiologic data for this organism are limited. We describe the epidemiology, clinical characteristics, and outcomes for patients with extensively drug-resistant Acinetobacter baumannii (XDRAB). Design: Retrospective cohort study Setting: Department of Veterans’ Affairs Medical Centers (VAMCs) Participants: Patients with XDRAB cultures (defined as nonsusceptible to at least 1 agent in all but 2 or fewer classes) at VAMCs between 2012 and 2018. Methods: Microbiology and clinical data was extracted from national VA datasets. We used descriptive statistics to summarize patient characteristics and outcomes and bivariate analyses to compare outcomes by culture source. Results: Among 11,546 patients with 15,364 A. baumannii cultures, 408 (3.5%) patients had 667 (4.3%) XDRAB cultures. Patients with XDRAB were older (mean age, 68 years; SD, 12.2) with median Charlson index 3 (interquartile range, 1–5). Respiratory specimens (n = 244, 36.6%) and urine samples (n = 187, 28%) were the most frequent sources; the greatest proportion of patients were from the South (n = 162, 39.7%). Most patients had had antibiotic exposures (n = 362, 88.7%) and hospital or long-term care admissions (n = 331, 81%) in the prior 90 days. Polymyxins, tigecycline, and minocycline demonstrated the highest susceptibility. Also, 30-day mortality (n = 96, 23.5%) and 1-year mortality (n = 199, 48.8%) were high, with significantly higher mortality in patients with blood cultures. Conclusions: The proportion of Acinetobacter baumannii in the VA that was XDR was low, but treatment options are extremely limited and clinical outcomes were poor. Prevention of healthcare-associated XDRAB infection should remain a priority, and novel antibiotics for XDRAB treatment are urgently needed.

Download Full-text

Inpatient Management of Uncomplicated Skin and Soft Tissue Infections in 34 Veterans Affairs Medical Centers: A Medication Use Evaluation

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz554 ◽

2020 ◽

Vol 7 (1) ◽

Author(s):

Jesse D Sutton ◽

Ronald Carico ◽

Muriel Burk ◽

Makoto M Jones ◽

XiangMing Wei ◽

...

Keyword(s):

Soft Tissue ◽

Antimicrobial Stewardship ◽

Broad Spectrum ◽

Medication Use ◽

Antibiotic Use ◽

Veterans Affairs ◽

Soft Tissue Infections ◽

Gram Negative ◽

Medical Centers ◽

Veterans Affairs Medical Centers

Abstract Background Skin and soft tissue infections (SSTIs) are a key antimicrobial stewardship target because they are a common infection in hospitalized patients, and non-guideline-concordant antibiotic use is frequent. To inform antimicrobial stewardship interventions, we evaluated the proportion of veterans hospitalized with SSTIs who received guideline-concordant empiric antibiotics or an appropriate total duration of antibiotics. Methods A retrospective medication use evaluation was performed in 34 Veterans Affairs Medical Centers between 2016 and 2017. Hospitalized patients who received antibiotics for uncomplicated SSTI were included. Exclusion criteria were complicated SSTI, severe immunosuppression, and antibiotics for any non-SSTI indication. Data were collected by manual chart review. The primary outcome was the proportion of patients receiving both guideline-concordant empiric antibiotics and appropriate treatment duration, defined as 5–10 days of antibiotics. Data were analyzed and reported using descriptive statistics. Results Of the 3890 patients manually evaluated for inclusion, 1828 patients met inclusion criteria. There were 1299 nonpurulent (71%) and 529 purulent SSTIs (29%). Overall, 250 patients (14%) received guideline-concordant empiric therapy and an appropriate duration. The most common reason for non-guideline-concordance was receipt of antibiotics targeting methicillin-resistant Staphylococcus aureus (MRSA) in 906 patients (70%) with a nonpurulent SSTI. Additionally, 819 patients (45%) received broad-spectrum Gram-negative coverage, and 860 patients (48%) received an antibiotic duration >10 days. Conclusions We identified 3 common opportunities to improve antibiotic use for patients hospitalized with uncomplicated SSTIs: use of anti-MRSA antibiotics in patients with nonpurulent SSTIs, use of broad-spectrum Gram-negative antibiotics, and prolonged durations of therapy.

Download Full-text

A pilot study using telehealth to implement antimicrobial stewardship at two rural Veterans Affairs medical centers

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2018.197 ◽

2018 ◽

Vol 39 (10) ◽

pp. 1163-1169 ◽

Cited By ~ 6

Author(s):

Lauren D. Stevenson ◽

Richard E. Banks ◽

Krysttel C. Stryczek ◽

Christopher J. Crnich ◽

Emma M. Ide ◽

...

Keyword(s):

Infectious Disease ◽

Pilot Study ◽

Acute Care ◽

Antimicrobial Stewardship ◽

Veterans Affairs ◽

Acceptance Rate ◽

Term Care ◽

Limited Access ◽

Medical Centers ◽

Veterans Affairs Medical Centers

AbstractObjectiveTo test the feasibility of using telehealth to support antimicrobial stewardship at Veterans Affairs medical centers (VAMCs) that have limited access to infectious disease-trained specialists.DesignA prospective quasi-experimental pilot study.SettingTwo rural VAMCs with acute-care and long-term care units.InterventionAt each intervention site, medical providers, pharmacists, infection preventionists, staff nurses, and off-site infectious disease physicians formed a videoconference antimicrobial stewardship team (VAST) that met weekly to discuss cases and antimicrobial stewardship-related education.MethodsDescriptive measures included fidelity of implementation, number of cases discussed, infectious syndromes, types of recommendations, and acceptance rate of recommendations made by the VAST. Qualitative results stemmed from semi-structured interviews with VAST participants at the intervention sites.ResultsEach site adapted the VAST to suit their local needs. On average, sites A and B discussed 3.5 and 3.1 cases per session, respectively. At site A, 98 of 140 cases (70%) were from the acute-care units; at site B, 59 of 119 cases (50%) were from the acute-care units. The most common clinical syndrome discussed was pneumonia or respiratory syndrome (41% and 35% for sites A and B, respectively). Providers implemented most VAST recommendations, with an acceptance rate of 73% (186 of 256 recommendations) and 65% (99 of 153 recommendations) at sites A and B, respectively. Qualitative results based on 24 interviews revealed that participants valued the multidisciplinary aspects of the VAST sessions and felt that it improved their antimicrobial stewardship efforts and patient care.ConclusionsThis pilot study has successfully demonstrated the feasibility of using telehealth to support antimicrobial stewardship at rural VAMCs with limited access to local infectious disease expertise.

Download Full-text

Does universal active MRSA surveillance influence anti-MRSA antibiotic use? A retrospective analysis of the treatment of patients admitted with suspicion of infection at Veterans Affairs Medical Centers between 2005 and 2010

Journal of Antimicrobial Chemotherapy ◽

10.1093/jac/dku299 ◽

2014 ◽

Vol 69 (12) ◽

pp. 3401-3408 ◽

Cited By ~ 6

Author(s):

M. Jones ◽

B. Huttner ◽

M. Leecaster ◽

A. Huttner ◽

K. Damal ◽

...

Keyword(s):

Retrospective Analysis ◽

Antibiotic Use ◽

Veterans Affairs ◽

Medical Centers ◽

Veterans Affairs Medical Centers

Download Full-text

Infections and use of antibiotics in residents of long-term care facilities in Hungary

Orvosi Hetilap ◽

10.1556/oh.2014.29876 ◽

2014 ◽

Vol 155 (23) ◽

pp. 911-917 ◽

Cited By ~ 1

Author(s):

Rita Szabó ◽

Karolina Böröcz

Keyword(s):

Urinary Tract ◽

Long Term Care ◽

Soft Tissues ◽

Good Practice ◽

Antibiotic Use ◽

Prevalence Survey ◽

Term Care ◽

Care Facilities ◽

Tract Infections

Introduction: Healthcare associated infections and antimicrobial use are common among residents of long-term care facilities. Faced to the lack of standardized data, the European Centre for Disease Prevention and Control funded a project with the aim of estimating prevalence of infections and antibiotic use in European long-term care facilities. Aim: The aim of the authors was to present the results of the European survey which were obtained in Hungary. Method: In Hungary, 91 long-term care facilities with 11,823 residents participated in the point-prevalence survey in May, 2013. Results: The prevalence of infections was 2.1%. Skin and soft tissues infections were the most frequent (36%), followed by infections of the respiratory (30%) and urinary tract (21%). Antimicrobials were mostly prescribed for urinary tract infections (40.3%), respiratory tract infections (38.4%) and skin and soft tissue infections (13.2%). The most common antimicrobials (97.5%) belonged to the ATC J01 class of “antibacterials for systemic use”. Conclusions: The results emphasise the need for a national guideline and education for good practice in long-term care facilities. Orv. Hetil., 2014, 155(23), 911–917.

Download Full-text