The CLABSI Playbook: Design and Implementation of a Multipronged Approach to Decrease CLABSIs.

ABSTRACT: Central line-associated blood stream infections (CLABSIs) are a quality marker for the critical care environment. They have become an area of particular interest because they cost the healthcare system close to a billion dollars per year and have a significant impact on patient safety. Through a preliminary analysis of our system's CLABSI rates, we found significantly higher rates than the national average, prompting further investigation. We decreased our CLABSI rate by over 40% from 2021 (1.6 per 1,000 line days) to the fourth quarter of 2022 (0.91) and kept the rate below or around the national rate (0.86) for the last three quarters of 2022. Through looking at current outcome data, identifying key stakeholders, developing dedicated committees, conducting root cause analyses, monitoring progress, adjusting procedures, scaling to the system, and continuously monitoring and reporting results, we have shown the efficacy of this kind of quality improvement structure and strive to reduce our hospital system's impact on avoidable healthcare-associated patient harm.

Acremonium (Sarocladium) periprosthetic joint infection: case report, literature review, and proposed antifungal regimen.

BACKGROUND: Fungal periprosthetic joint infections are rare. Acremonium osteoarticular infections are scarcely reported. Variable susceptibility to antifungal agents have been reported and optimal pharmacotherapy has yet to be established. Here we illustrate an Acremonium osteoarticular infection involving a prosthetic joint and present an antifungal regimen that had led to treatment success. CASE PRESENTATION: A 60-year-old female with a body mass index (BMI) of 40 had left total knee arthroplasty done in 2012 with a cementless implant for knee osteoarthritis. In 2019, the patient had asymptomatic, progressive osteolysis with fracture and migration of the femoral component warranting replacement. Eleven months later, the patient developed significant pain, redness, and swelling in the left leg and knee concerning for periprosthetic joint infection that failed outpatient antibiotic treatment. Further investigation revealed infection by Acremonium species. A revision of the joint was successfully completed, and the patient was placed on voriconazole for one year. Subsequent cultures did not yield any fungal growth. CONCLUSION: While an optimal antifungal regimen for periprosthetic joint infections has not been well established, voriconazole is a relatively safe and effective agent that can be used as a long-term therapy. With variable susceptibility testing in reported isolates, individualized antifungal susceptibility should be used to guide therapy for Acremonium infections.

Implementing Clinical Practice Guidelines for Replacing Peripheral Intravenous Catheters.

BACKGROUND: A community hospital policy of routinely replacing peripheral intravenous catheters (PIVCs) needed updating to the clinical practice guideline (CPG) of clinically indicated replacement. METHODS: Guided by Lean principles, a clinical nurse leader (CNL) led a quality improvement small test of change on a 38-bed medical unit. The impact of the CPG was evaluated using quality, safety, and workflow measures. RESULTS: Nurses managed 469 inpatients, receiving 1033 PIVCs. Routine PIVC replacement declined from 34% to 3% (P < .001). PIVC dwell time ranged from 4 to 20 days and did not increase phlebitis (P = .41) or catheter-related bloodstream infections. Nurses attributed the improvements in workflow (P = .01) and the quality of patient care (94%) to the updated PIVC guideline. CONCLUSIONS: Clinically-indicated PIVC replacement reduced unnecessary catheter insertions, maintained patient safety, improved efficiency, and is being implemented hospital-wide. This project highlights and advances the CNL role in transforming healthcare.

Sustained reduction of central line-associated bloodstream infections outside the intensive care unit with a multimodal intervention focusing on central line maintenance.

BACKGROUND: Central venous catheter use is common outside the intensive care units (ICUs), but prevention in this setting is not well studied. We initiated surveillance for central line-associated bloodstream infections (CLABSIs) outside the ICU setting and studied the impact of a multimodal intervention on the incidence of CLABSIs across multiple hospitals. METHODS: This project was constructed as a prospective preintervention-postintervention design. The project comprised 3 phases (preintervention [baseline], intervention, and postintervention) over a 4.5-year period (2008-2012) and was implemented through a collaborative of 37 adult non-ICU wards at 6 hospitals in the Rochester, NY area. The intervention focused on engagement of nursing staff and leadership, nursing education on line care maintenance, competence evaluation, audits of line care, and regular feedback on CLABSI rates. Quarterly rates were compared over time in relation to intervention implementation. RESULTS: The overall CLABSI rate for all participating units decreased from 2.6/1000 line-days preintervention to 2.1/1,000 line-days during the intervention and to 1.3/1,000 line-days postintervention, a 50% reduction (95% confidence interval, .40-.59) compared with the preintervention period (P .0179). CONCLUSION: A multipronged approach blending both the adaptive and technical aspects of care including front line engagement, education, execution of best practices, and evaluation of both process and outcome measures may provide an effective strategy for reducing CLABSI rates outside the ICU.

Cache valley virus in a patient diagnosed with aseptic meningitis.

Cache Valley virus was initially isolated from mosquitoes and had been linked to central nervous system-associated diseases. A case of Cache Valley virus infection is described. The virus was cultured from a patient's cerebrospinal fluid and identified with real-time reverse transcription-PCR and sequencing, which also yielded the complete viral coding sequences.

Limitations of Cockcroft-Gault and MDRD formulas in estimating GFR among top-level rugby players.

INTRODUCTION: We measured serum creatinine concentrations in 17 male athletes of the Italian national rugby team. METHODS: Blood was obtained before the start of training and during the competitive season. Serum creatinine level was measured by Jaffé reaction at 4 time points during the season, with a formal measure of creatinine clearance in midseason. RESULTS: The values of estimated glomerular filtration rate (eGFR) calculated with the Cockcroft-Gault (CG) equation were higher than those calculated with the Modification of Diet in Renal Disease (MDRD) Study formula (p<0.001). This difference was significantly decreased but still present when the MDRD formula was corrected for body surface area (BSA). When compared with measured creatinine clearance (CrCl), the MDRD underestimates the CrCl by 51 ml/min (95% confidence interval [95% CI], 36-67 ml/min, p<0.0001). When corrected for BSA, this difference falls to 27 ml/min (95% CI, 13-44 ml/min, p=0.001). The CG eGFR gave a better estimate of CrCl, differing by 1 ml/min (95% CI, -16 to +17 ml/min, p=NS). CONCLUSIONS: The MDRD formula underestimates the CrCl in rugby players, even when corrected for BSA. Conversely, the CG formula more closely approximates the actual CrCl measurement. The equations to estimate GFR should be used with caution in subjects having atypical anthropometric characteristics.

Device use ratio measured weekly can reliably estimate central line-days for central line-associated bloodstream infection rates.

Six hospitals joined to perform surveillance for central line-associated bloodstream infections outside of intensive care units (ICUs). To facilitate the counting of device-days, a weekly measure of the device use ratio was validated as an estimate of central line-days outside the ICU.

Differential effects of pneumococcal vaccines against serotypes 6A and 6C.

BACKGROUND: Because classic pneumococcal serotyping methods cannot distinguish between serotypes 6A and 6C, the effects of pneumococcal vaccines against serotype 6C are unknown. Pneumococcal vaccines contain serotype 6B but not serotypes 6A and 6C. METHODS: We used a phagocytic killing assay to estimate the immunogenicity of the 7-valent conjugate vaccine (PCV7) in children and the 23-valent polysaccharide vaccine (PPV23) in adults against serotypes 6A and 6C. We evaluated trends in invasive pneumococcal disease (IPD) caused by serotypes 6A and 6C in the United States, using active surveillance. RESULTS: Serum specimens from PCV7-immunized children had median opsonization indices of 150 and < 20 for serotypes 6A and 6C, respectively. Similarly, only 52% of adults (25 of 48) vaccinated with PPV23 showed opsonic indices of > 20 against serotype 6C. During 1999--2006, the incidence of serotype 6A IPD decreased by 91% (from 4.9 to 0.46 cases per 100,000 persons; P < .05) among individuals aged < 5 years and by 58% (from 0.86 to 0.36 cases per 100,000 persons; P < .05) among those aged > or = 5 years. Although the incidence of 6C IPD showed no consistent trend (range, 0-0.6 cases per 100,000 persons) among individuals aged < 5 years, it increased from 0.25 to 0.62 cases per 100,000 persons (P < .05) among those aged > or = 5 years. CONCLUSIONS: PCV7 introduction has led to reductions in serotype 6A IPD but not serotype 6C IPD in the United States.

Normalization of lithium-induced hypercalcemia and hyperparathyroidism with cinacalcet hydrochloride.

An underrecognized side effect of long-term lithium carbonate therapy is hyperparathyroidism with associated hypercalcemia and hypocalciuria. Because cessation of lithium carbonate therapy usually does not correct the hyperparathyroidism and associated hypercalcemia, parathyroidectomy frequently is necessary. This is the initial report of 2 patients with lithium carbonate-induced hyperparathyroidism treated with cinacalcet hydrochloride (HCl), which normalized serum calcium levels and reduced intact parathyroid hormone (iPTH) secretion. The patients, both with bipolar disease and a 15- to 30-year history of lithium carbonate therapy, were evaluated for stage 3 chronic kidney disease, persistent hypercalcemia, and hyperparathyroidism. A 67-year-old woman was administered cinacalcet HCl, 30 mg/d, for 11 months. Mean serum calcium level decreased from 10.8 +/- 0.4 mg/dL (2.69 +/- 0.10 mmol/L) to 9.9 +/- 0.4 mg/dL (2.47 +/- 0.10 mmol/L; P < 0.001), and iPTH level decreased from 139 +/- 31 pg/mL (139 +/- 31 ng/L) to 114 +/- 39 pg/mL (114 +/- 39 ng/L; P = not significant). A 63-year-old man was administered 30 mg/d of cinacalcet HCl for 8 months, then 60 mg/d for another 2 months. Mean serum calcium and iPTH levels decreased from 11.0 +/- 0.5 mg/dL (2.74 +/- 0.12 mmol/L) to 10.3 +/- 0.4 mg/dL (2.57 +/- 0.10 mmol/L; P < 0.001) and 138 +/- 10 pg/mL (138 +/- 10 ng/L) to 73 +/- 7 pg/mL (73 +/- 7 ng/L; P = 0.03), respectively. Urinary fractional excretion of calcium was low for both patients before (<0.026 and <0.015) and after (0.026 and 0.008) treatment with cinacalcet HCl. These findings suggest that cinacalcet HCl can provide an alternative nonsurgical means to control this disorder in patients with hypercalcemia of variable severity for whom surgical treatment is not a consideration because of perceived mildness of disease or unsuitability of the patient for surgical intervention.

A double-blind, placebo-controlled trial of intravenous iron dextran therapy in patients with ESRD and restless legs syndrome.

BACKGROUND: Restless legs syndrome (RLS) is a common disorder in patients with end-stage renal disease (ESRD) that causes motor agitation and insomnia. Because RLS has been associated with iron deficiency, we sought to investigate the effects of intravenous (IV) iron dextran on symptoms of RLS in a double-blind placebo-controlled trial. METHODS: Patients determined to have RLS by International RLS Study Group criteria were administered either iron dextran, 1,000 mg, or normal saline IV in a blinded fashion. Patient demographic data were collected, and blood chemistry tests, liver function studies, serum iron levels, ferritin levels, and total iron-binding capacity were obtained at baseline and 1, 2, and 4 weeks postinfusion. Side effects or adverse events to interventions were monitored, and RLS symptoms were assessed by a rating scale at the same intervals. RESULTS: Eleven patients were randomly assigned to the administration of iron dextran, and 14 patients to the administration of saline. RLS severity scores were slightly higher in the placebo group at baseline, but hemoglobin levels, iron stores, and other biochemical parameters did not differ. Although no change in symptoms were seen in the placebo-treated group, significant improvement in RLS symptom scores in response to iron dextran was seen 1 week after infusion (-2; interquartile range [IQR], -6 to -1; P = 0.03, Wilcoxon's rank sums), but was greatest at 2 weeks (-3; IQR, -5 to -2 compared with -1 to 0; P = 0.01). Salutary effects of iron persisted at 4 weeks, but were no longer statistically significant. The significant increase in serum ferritin levels and iron saturation observed in the iron dextran-treated group was not seen in the placebo-treated group. No differences in adverse events were noted between groups. CONCLUSION: High-dose iron dextran infusion is associated with a significant, but transient, reduction in symptoms of RLS in patients with ESRD.