Impact of a Cost Visibility Tool in the Electronic Medical Record on Antibiotic Prescribing in an Academic Medical Center.

BACKGROUND: Studies evaluating the impact of passive cost visibility tools on antibiotic prescribing are lacking. OBJECTIVE: The objective of this study was to evaluate whether the implementation of a passive antibiotic cost visibility tool would impact antibiotic prescribing and decrease antibiotic spending. METHODS: An efficiency and effectiveness initiative (EEI) was implemented in October 2012. To support the EEI, an antibiotic cost visibility tool was created in June 2013 displaying the relative cost of antibiotics. Using an observational study of interrupted time series design, 3 time frames were studied: pre EEI, post EEI, and post cost visibility tool implementation. The primary outcome was antibiotic cost per 1,000 patient days. Secondary outcomes included case mix index (CMI)-adjusted antibiotic cost per 1,000 patient days and utilization of the cost visibility tool. RESULTS: Initiation of the EEI was associated with a $4,675 decrease in antibiotic cost per 1,000 patient days (P = .003), and costs continued to decrease in the months following EEI (P = .009). After implementation of the cost visibility tool, costs remained stable (P = .844). Despite CMI increasing over time, adjustment for CMI had no impact on the directionality or statistical significance of the results. CONCLUSION: Our study demonstrated a significant and sustained decrease in antibiotic cost per 1,000 patient days when focused medication cost reduction efforts were implemented, but passive cost visibility tool implementation was not associated with additional cost reduction. Antibiotic cost visibility tools may be of most benefit when prior medication cost reduction efforts are lacking or when an active intervention is incorporated.

Kerstersia gyiorum Isolated from a Bronchoalveolar Lavage in a Patient with a Chronic Tracheostomy.

The use of the matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) mass spectrometry (MS) generates rapid microbial identification. We are presenting a case of a 63-year-old woman with a medical history of chronic tracheostomy admitted for hypotension and fevers to illustrate the clinical implication of MALDI-TOF MS on bacterial identification. Kerstersia gyiorum was identified from the bronchoalveolar lavage isolate. Kerstersia gyiorum has been isolated from human sputum samples, and may be a previously unrecognized colonizer of the upper respiratory tract. Thus, patients with long-term tracheotomies or who are chronically aspirating may be at risk of lower respiratory infection with this organism. Increased use of MALDI-TOF MS in the clinical setting may increase reporting of this atypical isolate.

Nephrotoxicity Risk Factors and Intravenous Vancomycin Dosing in the Immediate Postoperative Period Following Antibiotic-Impregnated Cement Spacer Placement.

BACKGROUND: Several case reports have documented acute kidney injury (AKI) attributable to antibiotic-impregnated cement (AIC) spacers. OBJECTIVES: To identify AKI risk factors among patients who underwent AIC placement and determine whether vancomycin-AIC placement affects systemic vancomycin dosing. METHODS: Phase 1 was a case-control study to identify AKI risk factors among patients who underwent AIC placement. Cases experienced AKI; controls had unchanged renal function. Phase 2 was a retrospective cohort study. Patients who received ≥72 hours of intravenous (IV) vancomycin were divided into 2 groups according to whether they underwent vancomycin-AIC placement. Primary outcome was number of vancomycin dosing changes. RESULTS: Phase 1: Among 26 cases and 74 controls AKI risk factors on univariate and multivariable analysis included exposure to angiotensin-converting-enzyme (ACE) inhibitor exposure within 7 days of AIC placement (42% vs 20%, P = 0.03) and piperacillin-tazobactam within 7 days following AIC placement (31% vs 12%, P = 0.03). Phase 2: Among 53 patients who underwent vancomycin-AIC placement and 104 who underwent another surgery type, vancomycin was adjusted more frequently in patients who underwent vancomycin-AIC placement (28% vs 15%, P = 0.06). CONCLUSIONS: Among patients who undergo AIC placement with vancomycin and/or tobramycin, exposure to ACE inhibitors and piperacillin-tazobactam are associated with increased risk of AKI in the immediate postoperative period. No empirical adjustments to IV vancomycin dosing are necessary in patients undergoing vancomycin-AIC placement.

Putting surveillance data into context: the role of health care utilization surveys in understanding population burden of pneumonia in developing countries.

BACKGROUND: Surveillance is essential to estimating the global burden of pneumonia, yet differences in surveillance methodology and health care-seeking behaviors limit inter-country comparisons. METHODS: Results were compared from community surveys measuring health care-seeking for pneumonia defined as: (1) cough and difficulty breathing for ⩾2days; or, (2) provider-diagnosed pneumonia. Surveys were conducted in six sites in Guatemala, Kenya and Thailand; these sites also conduct, active, hospital- and population-based disease surveillance for pneumonia. RESULTS: Frequency of self-reported pneumonia during the preceding year ranged from 1.1% (Thailand) to 6.3% (Guatemala) and was highest in children aged <5years and in urban sites. The proportion of persons with pneumonia who sought hospital-based medical services ranged from 12% (Guatemala, Kenya) to 80% (Thailand) and was highest in children <5years of age. Hospitals and private provider offices were the most common places where persons with pneumonia sought health care. The most commonly cited reasons for not seeking health care were: (a) mild illness; (b) already recovering; and (3) cost of treatment. CONCLUSIONS: Health care-seeking patterns varied widely across countries. Using results from standardized health care utilization surveys to adjust facility-based surveillance estimates of pneumonia allows for more accurate and comparable estimates.

Incidence and severity of invasive Streptococcus pneumoniae, group A Streptococcus, and group B Streptococcus infections among pregnant and postpartum women.

BACKGROUND: The epidemiology of streptococcal infection in pregnant and postpartum women is poorly described in recent literature. We used data from multistate surveillance for invasive Streptococcus pneumoniae, group A Streptococcus (GAS), and group B Streptococcus (GBS) infections to estimate disease incidence and severity in these populations. METHODS: Cases were reported through the Centers for Disease Control and Prevention Active Bacterial Core surveillance, an active population- and laboratory-based system. A case was defined as illness in a woman aged 15-44 years with streptococcus isolated from a normally sterile body site during 2007-2009. Pregnant or postpartum status was recorded at the time of culture. Incidence was calculated as cases per 1000 woman-years with use of national Census data; 95% confidence intervals were calculated on the basis of λ distribution. We used multivariable logistic regression to explore associations between pregnant or postpartum status and hospital length of stay, a marker of disease severity. RESULTS: We identified 1848 cases in women; 6.0% of women were pregnant, and 7.5% were postpartum. Pregnant women had a higher mean incidence of GBS disease, compared with nonpregnant women (0.04 cases per 1000 woman-years [range, 0.03-0.05 cases per 1000 woman-years] vs 0.02 cases per 1000 woman-years [range, 0.02-0.02 cases per 1000 woman-years]). Postpartum women had elevated mean incidence of all 3 pathogens, compared with nonpregnant women (S. pneumoniae: 0.15 cases per 1000 woman-years [range, 0.09-0.25 cases per 1000 woman-years] vs 0.052 cases per 1000 woman-years [range, 0.049-0.056 cases per 1000 woman-years]; GAS: 0.56 cases per 1000 woman-years [range, 0.42-0.70 cases per 1000 woman-years] vs 0.019 cases per 1000 woman-years [range, 0.017-0.021 cases per 1000 woman-years]; GBS: 0.49 cases per 1000 woman-years [range, 0.36-0.64 cases per 1000 woman-years] vs 0.018 [range, 0.016-0.020 cases per 1000 woman-years]). Neither pregnancy nor postpartum status was associated with longer length of stay among women infected with any of the 3 pathogens. CONCLUSIONS: Although invasive streptococcal infections do not appear to be more severe in pregnant or postpartum women, postpartum women have a 20-fold increased incidence of GAS and GBS, compared with nonpregnant women.

Investigation of a group A streptococcal outbreak among residents of a long-term acute care hospital.

BACKGROUND: In January 2008, a long-term acute care hospital (LTACH) in New Mexico reported a cluster of severe group A Streptococcus (GAS) infections. METHODS: We defined a case as illness in a patient in the LTACH from 1 October 2007 through 3 February 2008 from whom GAS was isolated from a usually sterile site or with illness consistent with GAS infection and GAS isolated from a nonsterile site. To identify carriers, we swabbed the oropharynx and skin lesions of patients and staff. We observed facility procedures to assess possible transmission routes and adherence to infection control practices. We also conducted a case-control study to identify risk factors for infection with use of asymptomatic patients who were noncarriers as control subjects. RESULTS: We identified 11 case patients and 11 carriers (8 patients and 3 staff). No carriers became case patients. Significant risk factors for infection in univariate analysis included sharing a room with an infected or colonized patient (6 [55%] of 11 case patients vs 3 [8%] of 39 control subjects), undergoing wound debridement (64% vs 13%), and receiving negative pressure wound therapy (73% vs 33%). Having an infected or colonized roommate remained associated with case patients in multivariable analysis (odds ratio, 15.3; 95% confidence interval, 2.5-110.9). Suboptimal infection control practices were widespread. CONCLUSIONS: This large outbreak of GAS infection was the first reported in an LTACH, a setting that contains a highly susceptible patient population. Widespread infection control lapses likely allowed continued transmission. Similar to the situation in other care settings, appropriate infection control and case cohorting may help prevent and control outbreaks of GAS infection in LTACHs.

Hospitalized patients with 2009 H1N1 influenza in the United States, April-June 2009.

BACKGROUND: During the spring of 2009, a pandemic influenza A (H1N1) virus emerged and spread globally. We describe the clinical characteristics of patients who were hospitalized with 2009 H1N1 influenza in the United States from April 2009 to mid-June 2009. METHODS: Using medical charts, we collected data on 272 patients who were hospitalized for at least 24 hours for influenza-like illness and who tested positive for the 2009 H1N1 virus with the use of a real-time reverse-transcriptase-polymerase-chain-reaction assay. RESULTS: Of the 272 patients we studied, 25% were admitted to an intensive care unit and 7% died. Forty-five percent of the patients were children under the age of 18 years, and 5% were 65 years of age or older. Seventy-three percent of the patients had at least one underlying medical condition; these conditions included asthma; diabetes; heart, lung, and neurologic diseases; and pregnancy. Of the 249 patients who underwent chest radiography on admission, 100 (40%) had findings consistent with pneumonia. Of the 268 patients for whom data were available regarding the use of antiviral drugs, such therapy was initiated in 200 patients (75%) at a median of 3 days after the onset of illness. Data suggest that the use of antiviral drugs was beneficial in hospitalized patients, especially when such therapy was initiated early. CONCLUSIONS: During the evaluation period, 2009 H1N1 influenza caused severe illness requiring hospitalization, including pneumonia and death. Nearly three quarters of the patients had one or more underlying medical conditions. Few severe illnesses were reported among persons 65 years of age or older. Patients seemed to benefit from antiviral therapy.

Comparison of laboratory diagnostic procedures for detection of Mycoplasma pneumoniae in community outbreaks.

BACKGROUND: Mycoplasma pneumoniae continues to be a significant cause of community-acquired pneumonia (CAP). A more definitive methodology for reliable detection of M. pneumoniae is needed to identify outbreaks and to prevent potentially fatal extrapulmonary complications. METHODS: We analyzed 2 outbreaks of CAP due to M. pneumoniae. Nasopharyngeal and/or oropharyngeal swab specimens and serum samples were obtained from persons with clinically defined cases, household contacts, and asymptomatic individuals. Real-time polymerase chain reaction (PCR) for M. pneumoniae was performed on all swab specimens, and the diagnostic utility was compared with that of 2 commercially available serologic test kits. RESULTS: For cases, 21% yielded positive results with real-time PCR, whereas 81% and 54% yielded positive results with the immunoglobulin M and immunoglobulin G/immunoglobulin M serologic tests, respectively. For noncases, 1.8% yielded positive results with real-time PCR, whereas 63% and 79% yielded serologically positive results with the immunoglobulin M and immunoglobulin G/immunoglobulin M kits, respectively. The sensitivity of real-time PCR decreased as the duration between symptom onset and sample collection increased, with a peak sensitivity of 48% at 0-21 days. A specificity of 43% for the immunoglobulin M antibody detection assay was observed for persons aged 10-18 years, but the sensitivity increased to 82% for persons aged 19 years. DISCUSSION: Thorough data analysis indicated that no single available test was reliable for the identification of an outbreak of CAP due to M. pneumoniae. A combination of testing methodologies proved to be the most reliable approach for identification of outbreaks of CAP due to M. pneumoniae, especially in the absence of other suspected respiratory pathogens.

Hepatitis C virus infection does not preclude standard breast cancer-directed therapy.

In the United States, over 3 million people are infected with hepatitis C virus (HCV), and over 200,000 women develop breast cancer annually. Yet, no published studies have investigated the tolerability of breast cancer- directed therapy among women with HCV infection. We reviewed records at Memorial Sloan-Kettering Cancer Center and identified 35 patients with chronic HCV infection who were treated for breast cancer between the years 1991 and 2005. One (2.9%) of 35 also had chronic hepatitis B virus infection. There were no complications related to HCV infection during or after surgery or radiation therapy. A total of 29 (82.9%) of the 35 patients received chemotherapy for breast cancer. Of the 29, only 4 required chemotherapy delays or adjustments in dosing because of HCV infection. In conclusion, breast cancer therapy was well tolerated among women with HCV infection. Considering the paucity of complications, routine screening for HCV infection is not warranted among women with breast cancer and no defined risk factors for HCV infection.

Why some injection drug users lick their needles: a preliminary survey.

BACKGROUND: Injection drug users (IDUs) with poor hygiene practices are at risk for infection with their commensal flora. One example of a poor hygiene practice is licking the needle prior to injecting the drug. There are few published reports addressing the proportion of IDUs who lick their needles prior to injection and no prior studies evaluating the reasons for this practice. METHODS: We conducted face-to-face interviews with 40 IDUs admitted to the internal medicine service at our institution. We collected data regarding whether the subject licked the needle before injecting drugs, whether the subject licked the injection site before or after injecting drugs, and the reasons they report for doing so. RESULTS: Thirteen (32.5%, 95% CI, 18.6-49.1) of 40 subjects reported licking their needles prior to injecting. Reasons included ritualistic practices, cleaning the needle, enjoying the taste of the drug, checking the "quality" of the drug, and checking that the needle was in usable condition. CONCLUSIONS: In our study, approximately one-third of IDUs licked their needles prior to injecting. More data are needed to demonstrate whether the practice of needle licking significantly increases a person's risk for infection with oropharyngeal flora. Medical providers should ask patients about specific practices surrounding injection drug use, and educate drug users about avoiding unhygienic injection practices.

Knowledge of hepatitis among active drug injectors at a syringe exchange program.

Injecting drug users (IDUs) are at high risk for contracting and spreading viral hepatitis through nonsterile injection practices, unprotected sexual contact, and unsanitary living conditions. We sought to characterize hepatitis knowledge, prior testing, and vaccination history among IDUs at a New York City syringe exchange program (SEP). IDU subjects generally had a poor understanding of viral hepatitis transmission and prevention. We also found low vaccination rates: only 8% reported receiving hepatitis A vaccine and 11%, hepatitis B vaccine. Educating IDUs about risky behaviors and medical preventive interventions, such as vaccines for hepatitis A and B and treatment for hepatitis C, may help prevent disease and reduce transmission. Stronger linkages between health-care centers and SEPs, drug treatment programs, and other service delivery centers where IDUs are encountered may promote hepatitis education and vaccination.