Implementation of an Evidence-Based Care Program Within a Multihospital Health Care System.

The need for evidence-based guidance at the local hospital level is challenged by lack of clinician resources to critically appraise and synthesize evidence, and the applicability and timing of external evidence reviews are not always ideal for local settings. BJC HealthCare established an Evidence-Based Care (EBC) program to address evidence synthesis needs within the organization using a standardized rapid review process. From 2012 to 2016, 377 rapid reviews were completed. Common review topics included supplies or technology (23%), infection prevention (20%), and patient safety (18%). The median turnaround time for reviews was 22 calendar days (16 business days). Of the 68% (28/41) of review requestors who responded to a survey, 89% agreed or strongly agreed that EBC's review informed their project or final decision, and 93% indicated that they likely would request a review in the future. Using rapid review methodology, an EBC program delivered timely and relevant evidence for local decision making.

Attributable costs of enterococcal bloodstream infections in a nonsurgical hospital cohort.

BACKGROUND: Vancomycin-resistant Enterococcus (VRE) bloodstream infections (BSIs) are associated with increased morbidity and mortality. OBJECTIVE: To determine the hospital costs and length of stay attributable to VRE BSI and vancomycin-sensitive Enterococcus (VSE) BSI and the independent effect of vancomycin resistance on hospital costs. METHODS: A retrospective cohort study was conducted of 21,154 nonsurgical patients admitted to an academic medical center during the period from 2002 through 2003. Using administrative data, attributable hospital costs (adjusted for inflation to 2007 US dollars) and length of stay were estimated with multivariate generalized least-squares (GLS) models and propensity score-matched pairs. RESULTS: The cohort included 94 patients with VRE BSI and 182 patients with VSE BSI. After adjustment for demographics, comorbidities, procedures, nonenterococcal BSI, and early mortality, the costs attributable to VRE BSI were $4,479 (95% confidence interval [CI], $3,500-$5,732) in the standard GLS model and $4,036 (95% CI, $3,170-$5,140) in the propensity score-weighted GLS model, and the costs attributable to VSE BSI were $2,250 (95% CI, $1,758-$2,880) in the standard GLS model and $2,023 (95% CI, $1,588-$2,575) in the propensity score-weighted GLS model. The median values of the difference in costs between matched pairs were $9,949 (95% CI, $1,579-$24,693) for VRE BSI and $5,282 (95% CI, $2,042-$8,043) for VSE BSI. The costs attributable to vancomycin resistance were $1,713 (95% CI, $1,338-$2,192) in the standard GLS model and $1,546 (95% CI, $1,214-$1,968) in the propensity score-weighted GLS model. Depending on the statistical method used, attributable length of stay estimates ranged from 2.2 to 3.5 days for patients with VRE BSI and from 1.1 to 2.2 days for patients with VSE BSI. CONCLUSIONS: VRE BSI and VSE BSI were independently associated with increased hospital costs and increased length of stay. Vancomycin resistance was associated with increased costs.

Case-control study of clinical features of influenza in hospitalized patients.

BACKGROUND: The symptoms of influenza infection in outpatients are well described. The Centers for Disease Control and Prevention (CDC) definition of an influenza-like illness (ILI) includes fever and cough or sore throat. Few data exist on the clinical presentation of influenza in hospitalized patients, which may be distinct from the clinical presentation of influenza in ambulatory patients because of underlying medical conditions and medications. DESIGN: Retrospective case-control study. SETTING: A 1,250-bed urban teaching hospital. PATIENTS: A total of 369 patients were admitted to the general medicine wards during 3 consecutive influenza seasons (2001-2004): 123 case patients with laboratory-confirmed influenza that was diagnosed during routine medical care and 246 control patients with active surveillance culture results negative for influenza. METHODS: Data on demographic characteristics, comorbidities, and signs and symptoms were obtained from a review of the medical records of the case and control patients. Analysis included stratified analysis and logistic regression. RESULTS: Cough, coryza, sore throat, and fever were more common in patients with influenza infection. The CDC's definition of an ILI had a sensitivity of 43% and specificity of 86% in the study population, with a crude odds ratio (OR) of 4.7 (95% confidence interval [CI], 2.8-7.8). The sensitivity of the CDC's definition of an ILI decreased to 21% among asthmatic patients, who had similar rates of fever and/or ILI with or without influenza. By logistic regression, ILI was strongly associated with influenza infection in patients without asthma (adjusted OR, 7.5 [95% CI, 4.1-13.7]) but not in patients with asthma (adjusted OR, 1.1 [95% CI, 0.13-10]). The positive predictive value of an ILI in asthmatic patients was 50%. CONCLUSIONS: The CDC's definition of an ILI lacks sensitivity among hospitalized patients, and the presence of an ILI is not associated with influenza infection in asthmatic patients.

Impact of a methicillin-resistant Staphylococcus aureus active surveillance program on contact precaution utilization in a surgical intensive care unit.

OBJECTIVE: To determine the impact of an active surveillance for methicillin-resistant Staphylococcus aureus (MRSA) on contact precaution utilization, as measured by additional number of contact precaution days attributable to the active surveillance program. DESIGN: Prospective cohort study. SETTING: Twenty-four-bed surgical intensive care unit (ICU). PATIENTS: All patients admitted to the surgical ICU. INTERVENTIONS: Nasal cultures for MRSA were performed at admission to a surgical ICU for 19 months. Patients admitted>48 hrs also received weekly and discharge nasal cultures. MEASUREMENTS AND MAIN RESULTS: Clinical data, including start date and initial indication for contact precautions, were prospectively collected. Of 1,893 admissions, 253 (13%) were found to be MRSA-positive during their ICU stay. One hundred forty-six (58%) were identified by nasal culture alone. Compared with the first 10 months of study, the prevalence of MRSA on admission to the ICU during the last 9 months of the study period significantly increased (7.2% vs. 11.4%, p<.001). Acquisition of MRSA by noncolonized patients remained constant between the first 10 months and last 9 months of study (7.0 vs. 5.5 cases per 1000 patient days, p=.29). Two hundred fourteen (6%) of 3461 total contact precaution days in the ICU were attributable to MRSA active surveillance. In sensitivity analyses, the implementation of rapid, same-day results for MRSA active surveillance would increase contact precaution days by 15% compared with no surveillance. If the total number of vancomycin-resistant enterococci patients in the ICU were reduced by 50%, the contact precaution days attributable to active surveillance would increase to 9%. CONCLUSIONS: MRSA active surveillance increased total contact precaution days in this ICU by 6% yet detected 58% of MRSA cases that would have been otherwise missed. Despite an increasing prevalence of MRSA on admission to the ICU, the acquisition rate has remained constant.

The impact of an antibiotic cycling program on empirical therapy for gram-negative infections.

BACKGROUND: Antimicrobial-resistant organisms are an emerging problem in the ICU. Therapy cycling empiric antibiotics between various classes may influence bacterial resistance patterns. Understanding the impact of cycling on the appropriate treatment of suspected Gram-negative infections is important. METHODS: Data were prospectively collected on patients who were admitted to a 19-bed medical ICU (MICU). A total of 1,172 patients were admitted to the MICU for > 48 h and were evaluated during a 28.5-month period. After 4.5 months of baseline data collection, an antibiotic-cycling protocol was implemented, using four different antibiotic classes with Gram-negative activity that were cycled every 3 to 4 months. Therapy was considered to be inappropriate if the subsequent bacterial isolate was resistant to the empiric drug used. RESULTS: There were 59 bloodstream infections (BSIs), 17 ventilator-associated pneumonias (VAPs), and 101 urinary tract infections (UTIs) involving Gram-negative bacteria among 139 patients. Fifty-five infections (31%) were due to Gram-negative bacteria resistant to one or more antibiotic agents (BSIs, 18 [30%]; VAPs, 4 [23%]; and UTIs, 33 [33%]). Fifteen patients received inappropriate empiral therapy for 18 resistant Gram-negative infections (BSIs, 7 [39%]; VAPs, 3 [75%]; UTIs, 8 [24%]). Patients receiving inappropriate therapy were more likely to die (10 patients [67%] vs 40 patients [32%], respectively; p < 0.01). There was no difference in the receipt of appropriate empirical antibiotic therapy during the baseline compared to cycling (infectious episodes, 15% vs 10%, respectively; p = 0.4). CONCLUSIONS: Antimicrobial resistance occurred in almost 30% of ICU infections involving Gram-negative bacteria. Antibiotic cycling was not associated with significant changes in the receipt of appropriate empirical antimicrobial therapy for the treatment of ICU infections.

Epidemiology of methicillin-resistant Staphylococcus aureus colonization in a surgical intensive care unit.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) is a cause of healthcare-associated infections among surgical intensive care unit (ICU) patients, though transmission dynamics are unclear. OBJECTIVE: To determine the prevalence of MRSA nasal colonization at ICU admission, to identify associated independent risk factors, to determine the value of these factors in active surveillance, and to determine the incidence of and risk factors associated with MRSA acquisition. DESIGN: Prospective cohort study. SETTING: Surgical ICU at a teaching hospital. PATIENTS: All patients admitted to the surgical ICU. RESULTS: Active surveillance for MRSA by nasal culture was performed at ICU admission during a 15-month period. Patients who stayed in the ICU for more than 48 hours had nasal cultures performed weekly and at discharge from the ICU, and clinical data were collected prospectively. Of 1,469 patients, 122 (8%) were colonized with MRSA at admission; 75 (61%) were identified by surveillance alone. Among 775 patients who stayed in the ICU for more than 48 hours, risk factors for MRSA colonization at admission included the following: hospital admission in the past year (1-2 admissions: adjusted odds ratio [aOR], 2.60 [95% confidence interval {CI}, 1.47-4.60]; more than 2 admissions: aOR, 3.56 [95% CI, 1.72-7.40]), a hospital stay of 5 days or more prior to ICU admission (aOR, 2.54 [95% CI, 1.49-4.32]), chronic obstructive pulmonary disease (aOR, 2.16 [95% CI, 1.17-3.96]), diabetes mellitus (aOR, 1.87 [95% CI, 1.10-3.19]), and isolation of MRSA in the past 6 months (aOR, 8.18 [95% CI, 3.38-19.79]). Sixty-nine (10%) of 670 initially MRSA-negative patients acquired MRSA in the ICU (corresponding to 10.7 cases per 1,000 ICU-days at risk). Risk factors for MRSA acquisition included tracheostomy in the ICU (aOR, 2.18 [95% CI, 1.13-4.20]); decubitus ulcer (aOR, 1.72 [95% CI, 0.97-3.06]), and receipt of enteral nutrition via nasoenteric tube (aOR, 3.73 [95% CI, 1.86-7.51]), percutaneous tube (aOR, 2.35 [95% CI, 0.74-7.49]), or both (aOR, 3.33 [95% CI, 1.13-9.77]). CONCLUSIONS: Active surveillance detected a sizable proportion of MRSA-colonized patients not identified by clinical culture. MRSA colonization on admission was associated with recent healthcare contact and underlying disease. Acquisition was associated with potentially modifiable processes of care.

Is influenza an influenza-like illness? Clinical presentation of influenza in hospitalized patients.

BACKGROUND: Early recognition of influenza virus infection in hospitalized patients can prevent nosocomial transmission. OBJECTIVE: To determine the clinical presentation of influenza in hospitalized patients. DESIGN: Case series. Data were collected retrospectively from medical records and included demographic information, comorbidities, clinical symptoms and signs, microbiologic test results, and outcomes (including pneumonia and intensive care unit [ICU] admission). SETTING: A 1,400-bed teaching hospital. PATIENTS: A total of 207 inpatients who received a diagnosis of influenza virus infection during 3 seasons from 2000 to 2003. RESULTS: Over the course of 3 seasons, 207 patients received a diagnosis of influenza (186 were infected with influenza A virus, and 21 were infected with influenza B virus). The most commonly reported symptoms were cough (186 patients [90%]) and subjective fever (137 patients [66%]); 124 patients (60%) had a documented temperature of 37.8 degrees C or greater before influenza was diagnosed. Sore throat was uncommon (44 patients [21%]). Centers for Disease Control and Prevention (CDC) criteria for influenza-like illness (ILI)--temperature 37.8 degrees C or greater and either cough or sore throat--were met by 107 patients (51%). There were no differences in the proportion of patients who met ILI criteria with respect to age, sex, season, influenza virus type, or time to diagnosis in the hospital. Most patients (150 [72%]) received acetaminophen. Only 41 patients (20%) had positive results of clinical cultures; 178 patients (86%) received antibiotic therapy. Fifty-six patients (27%) had pneumonia: 36 (17%) required admission to the ICU, and 25 (12%) required ventilatory support. Patients with pulmonary disease were more likely to require ventilatory support (12 [26%] vs 13 [8%]; P =.003). CONCLUSIONS: Only half of hospitalized patients with influenza met CDC criteria for ILI. These criteria may be more appropriate in outpatient settings. A high index of suspicion is needed to recognize influenza in hospitalized patients.

Cycling empirical antimicrobial agents to prevent emergence of antimicrobial-resistant Gram-negative bacteria among intensive care unit patients.

OBJECTIVE: To determine the impact of the rotation of antimicrobial agents on the rates of infection, intestinal colonization, and acquisition with antimicrobial-resistant Gram-negative bacteria. DESIGN: Pre- and postintervention design. SETTING: A 19-bed, medical intensive care unit. PATIENTS: Individuals admitted to the study unit for >48 hrs. INTERVENTIONS: After a 5-month baseline observation period, four classes of antimicrobial agents with Gram-negative activity were cycled at 3- to 4-month intervals for 24 months. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the acquisition rate of antimicrobial resistance among Enterobacteriaceae and Pseudomonas aeruginosa obtained from rectal swab cultures performed on admission, weekly during the patients' stay, and at discharge. Rates and microbiology of nosocomial bloodstream infections and ventilator-associated pneumonia were also compared between baseline and cycling periods. The cycling program resulted in a significant change in prescribing practices; the predominant agent used changed with each cycle. Among study patients who were not already colonized with a resistant organism, the rate of acquisition of enteric colonization with bacteria resistant to any of the target drugs remained stable during the cycling period for P. aeruginosa (relative rate, 0.96; 95% confidence Interval, 0.47-2.16) and Enterobacteriaceae (relative rate, 1.57; 95% confidence interval, 0.80-3.43). Hospital-wide, P. aeruginosa from routine clinical cultures resistant to the target drugs increased during the cycling period. The proportion of Gram-negative bacteria isolated from cases of nosocomial bloodstream infection (29% baseline vs. 26% cycling; p = .11) and ventilator-associated pneumonia (80% vs. 41%; p = .06) did not significantly differ. CONCLUSIONS: In this study, antimicrobial cycling did not result in a significant change in enteric acquisition of resistant Gram-negative bacteria among intensive care unit patients.

Detection of methicillin-resistant Staphylococcus aureus directly from nasal swab specimens by a real-time PCR assay.

Screening for colonization with methicillin-resistant Staphylococcus aureus (MRSA) is a key aspect of infection control to limit the nosocomial spread of this organism. Current methods for the detection of MRSA in clinical microbiology laboratories, including molecularly based techniques, require a culture step and the isolation of pure colonies that result in a minimum of 20 to 24 h until a result is known. We describe a qualitative in vitro diagnostic test for the rapid detection of MRSA directly from nasal swab specimens (IDI-MRSA; Infectio Diagnostic, Inc., Sainte-Foy, Quebec, Canada), based upon a real-time PCR and direct detection of MRSA via amplicon hybridization with a fluorogenic target-specific molecular beacon probe. Samples from 288 patients were analyzed for the presence of MRSA with the IDI-MRSA assay, compared to detection by either direct plating or enrichment broth selective culture methods. The diagnostic values for this MRSA screening method were 91.7% sensitivity, 93.5% specificity, 82.5% positive predictive value, and 97.1% negative predictive value when compared to culture-based methods. The time from the start of processing of specimen to result was approximately 1.5 h. In our hands, the IDI-MRSA assay is a sensitive and specific test for detection of nasal colonization with MRSA and providing for same-day results, allowing more efficient and effective use of infection control resources to control MRSA in health care facilities.

Effects of an antibiotic cycling program on antibiotic prescribing practices in an intensive care unit.

Various interventions have been proposed to combat the increase of antibiotic resistance and influence antibiotic prescribing practices. A prospective cohort study in a medical intensive care unit was conducted to determine the effect of an antibiotic cycling program on patterns of antibiotic use and to determine patient factors associated with cycling adherence. Four major classes of antibiotics for empirical therapy of suspected gram-negative bacterial infections were rotated at 3- and 4-month intervals. During the study, 1,003 patients received antibiotic therapy with at least one of the study drugs; of the 792 receiving cycle antibiotics during the cycling period, 598 (75.5%) received an on-cycle drug. Compared to the baseline, cycling recommendations increased the use of the target cycle agent: the use of cephalosporins increased during cycle 1 (56 to 64% of total antibiotic days, P < 0.001), fluoroquinolone use increased in cycle 2 (24 to 55%, P < 0.001), carbapenem use increased during cycle 3 (14 to 38%, P < 0.001), and use of extended-spectrum penicillins increased in cycle 4 (5 to 36%, P < 0.001). Overall, 48% of total cycle antibiotic days were compliant with the cycling protocol. On average, 8.8 days per patient were spent receiving on-cycle drugs (range, 1 to 109). Cycle periods that specified carbapenem and fluoroquinolone use had the highest number of off-cycle days (62 and 64%). Predictors of on-cycle antibiotic use were increased severity of illness, as measured by an acute physiology and chronic health evaluation II score, and greater length of intensive care unit stay. In conclusion, the successful implementation of this cycling protocol increased antibiotic heterogeneity over time in the study unit.