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ObjectiveTo assess the effectiveness and acceptability of antimicrobial stewardship-focused implementation strategies on inpatient fluoroquinolones.MethodsStewardship champions at 15 hospitals were surveyed regarding the use and acceptability of strategies to improve fluoroquinolone prescribing. Antibiotic days of therapy (DOT) per 1,000 days present (DP) for sites with and without prospective audit and feedback (PAF) and/or prior approval were compared.ResultsAmong all of the sites, 60% had PAF or prior approval implemented for fluoroquinolones. Compared to sites using neither strategy (64.2 ± 34.4 DOT/DP), fluoroquinolone prescribing rates were lower for sites that employed PAF and/or prior approval (35.5 ± 9.8; P = .03) and decreased from 2017 to 2018 (P < .001). This decrease occurred without an increase in advanced-generation cephalosporins. Total antibiotic rates were 13% lower for sites with PAF and/or prior approval, but this difference did not reach statistical significance (P = .20). Sites reporting that PAF and/or prior approval were "completely" accepted had lower fluoroquinolone rates than sites where it was "moderately" accepted (34.2 ± 5.7 vs 48.7 ± 4.5; P < .01). Sites reported that clinical pathways and/or local guidelines (93%), prior approval (93%), and order forms (80%) "would" or "may" be effective in improving fluoroquinolone use. Although most sites (73%) indicated that requiring infectious disease consults would or may be effective in improving fluoroquinolones, 87% perceived implementation to be difficult.ConclusionsPAF and prior approval implementation strategies focused on fluoroquinolones were associated with significantly lower fluoroquinolone prescribing rates and nonsignificant decreases in total antibiotic use, suggesting limited evidence for class substitution. The association of acceptability of strategies with lower rates highlights the importance of culture. These results may indicate increased acceptability of implementation strategies and/or sensitivity to FDA warnings.

ObjectiveIn the absence of pyuria, positive urine cultures are unlikely to represent infection. Conditional urine reflex culture policies have the potential to limit unnecessary urine culturing. We evaluated the impact of this diagnostic stewardship intervention.DesignWe conducted a retrospective, quasi-experimental (nonrandomized) study, with interrupted time series, from August 2013 to January 2018 to examine rates of urine cultures before versus after the policy intervention. We compared 3 intervention sites to 3 control sites in an aggregated series using segmented negative binomial regression.SettingThe study included 6 acute-care hospitals within the Veterans' Health Administration across the United States.ParticipantsAdult patients with at least 1 urinalysis ordered during acute-care admission, excluding pregnant patients or those undergoing urological procedures, were included.MethodsAt the intervention sites, urine cultures were performed if a preceding urinalysis met prespecified criteria. No such restrictions occurred at the control sites. The primary outcome was the rate of urine cultures performed per 1,000 patient days. The safety outcome was the rate of gram-negative bloodstream infection per 1,000 patient days.ResultsThe study included 224,573 urine cultures from 50,901 admissions in 24,759 unique patients. Among the intervention sites, the overall average number of urine cultures performed did not significantly decrease relative to the preintervention period (5.9% decrease; P = 0.8) but did decrease by 21% relative to control sites (P < .01). We detected no significant difference in the rates of gram-negative bloodstream infection among intervention or control sites (P = .49).ConclusionsConditional urine reflex culture policies were associated with a decrease in urine culturing without a change in the incidence of gram-negative bloodstream infection.

Background Carbapenem-resistant Enterobacteriaceae (CRE) cause approximately 13 100 infections, with an 8% mortality rate in the United States annually. Carbapenemase-producing CRE (CP-CRE) a subset of CRE infections infections have much higher mortality rates (40%–50%). There has been little research on characteristics unique to CP-CRE. The goal of the current study was to assess differences between US veterans with non-CP-CRE and those with CP-CRE cultures. Methods A retrospective cohort of veterans with CRE cultures from 2013–2018 and their demographic, medical, and facility level covariates were collected. Clustered multiple logistic regression models were used to assess independent factors associated with CP-CRE. Results The study included 3096 unique patients with cultures positive for either non-CP-CRE or CP-CRE. Being African American (odds ratio, 1.44 [95% confidence interval, 1.15–1.80]), diagnosis in 2017 (3.11 [2.13–4.54]) or 2018 (3.93 [2.64–5.84]), congestive heart failure (1.35 [1.11–1.64]), and gastroesophageal reflux disease (1.39 [1.03–1.87]) were associated with CP-CRE cultures. There was no known antibiotic exposure in the previous year for 752 patients (24.3% of the included patients). Those with no known antibiotic exposure had increased frequency of prolonged proton pump inhibitor use (17.3%) compared to those with known antibiotic exposure (5.6%). Discussion Among a cohort of patients with CRE, African Americans, patients with congestive heart failure, and those with gastroesophageal reflux disease had greater odds of having a CP-CRE culture. Roughly 1 in 4 patients with CP-CRE had no known antibiotic exposure in the year before their positive culture. [ABSTRACT FROM AUTHOR]

Ceftolozane-tazobactam (C/T), ceftazidime-avibactam (C/A), and meropenem/vaborbactam (M/V) are new beta-lactam/beta-lactamase combination antibiotics commonly used to treat multidrug-resistant Pseudomonas aeruginosa (MDRPA) and carbapenem-resistant Enterobacteriaceae (CRE) infections. This review reports the clinical success rates for C/T, C/A, and M/V. PubMed and EMBASE were searched from January 1, 2012, through September 2, 2020, for publications detailing the use of C/T, C/A, and M/V. A meta-analysis determined the pooled effectiveness of C/T, C/A, and M/V. The literature search returned 1950 publications; 29 publications representing 1620 patients were retained. Pneumonia was the predominant infection type (49.8%). MDRPA was the major pathogen treated (65.3%). The pooled clinical success rate was 73.3% (95% CI, 68.9%–77.5%). C/T, C/A, or M/V resistance was reported in 8.9% of the population. These antibiotics had a high clinical success rate in patients with complicated infections and limited treatment options. Larger studies comparing C/T, C/A, and M/V against other antibiotic regimens are needed. [ABSTRACT FROM AUTHOR]

Highlights • Patients with spinal cord injury have high carbapenem-resistant Enterobacteriaceae (CRE) prevalence as opposed to the general population. • Variability in federal surveillance definitions affects CRE prevalence. • Inclusion of ertapenem resistance in the definition leads to higher CRE prevalence. • Almost all CRE was isolated from high-complexity, urban Department of Veterans Affairs medical centers. Background Patients with spinal cord injury (SCI) have a high risk for multidrug-resistant organisms, including carbapenem-resistant Enterobacteriaceae (CRE). Accurate and easily applied definitions are critical to identify CRE. This study describes CRE and associated characteristics in veterans with SCI per Centers for Disease Control and Prevention (CDC) and Department of Veterans Affairs (VA) definitions. Methods A retrospective cohort of veterans with SCI and more than 1 culture with Escherichia coli, Klebsiella spp and/or Enterobacter spp between 2012 and 2013 was examined. Antibiotic susceptibility criteria of pre-2015 (CDC1) and post-2015 (CDC2) CDC definitions and pre-2017 (VA1) and post-2017 (VA2) VA definitions were used to identify CRE. CRE prevalence and characteristics are described for isolates meeting each definition, and agreement was assessed with the Cohen kappa. Results We reviewed 21,514 isolates cultured from 6,974 veterans; 423 isolates met any CRE definition. Although agreement among definitions was high (kappa = 0.82-0.93), definitions including ertapenem resistance led to higher CRE prevalence (VA1 = 1.7% and CDC2 = 1.9% vs VA2 = 1.4% and CDC1 = 1.5%). Forty-four of 142 VA facilities had more than 1 CRE case defined by VA2; 10 facilities accounted for 60% of CRE cases. Almost all CRE was isolated from high-complexity, urban facilities, and the South had the highest proportion of CRE. Conclusions Varying federal definitions give different CRE frequencies in a high-risk population. Definitions including ertapenem resistance resulted in higher CRE prevalence but may overemphasize noncarbapenemase isolates. Thus, both federal definitions now highlight the importance of carbapenemase testing. [ABSTRACT FROM AUTHOR]

Background Multidrug-resistant (MDR) Acinetobacter is a growing concern and has been identified as a serious threat by the Centers for Disease Control and Prevention. However, there is little information on MDR Acinetobacter in individuals with spinal cord injuries and disorders (SCI/Ds). Therefore, the objective of this study was to identify risk factors for, and assess outcomes of, MDR Acinetobacter in veterans with SCI/Ds. Methods This was a retrospective cohort study from January 1, 2012-December 31, 2013, using national Veterans Affairs medical encounter and microbiology data. Results A total of 773 Acinetobacter cultures were identified in 571 patients, of which 58.9% were MDR. Inpatient culture, sputum and other specimen type, receipt of antibiotics within 90 days before culture date, and pressure ulcers were identified as independent predictors of MDR Acinetobacter . Highest odds of MDR Acinetobacter were seen with previous antibiotic use (odds ratio, 7.27; 95% confidence interval, 2.59-20.54). Thirty-day mortality was 5.3% in this study. Multidrug resistance, previous mechanical ventilation 90 days before the culture, and cancer were all independent risk factors for 30-day mortality. Conclusions There should be increased efforts to highlight the importance of antimicrobial stewardship to improve infection control to help limit spread of Acinetobacter in health care settings. [ABSTRACT FROM AUTHOR]

Clostridium difficile is the most frequently identified cause of nosocomial diarrhea and has been associated with epidemics of diarrhea in hospitals and long-term care facilities. The continued increase in C. difficile infection (CDI) suggests that it has surpassed other pathogens in causing healthcare-associated infections. The Centers for Disease Control and Prevention recently identified CDI as an "urgent threat" in its recent report on antibiotic resistance threats in the United States, highlighting the need for urgent and aggressive action to prevent this infection. The impact of antibiotics as a risk factor for new-onset CDI is well established; however, recognizing classes of antibiotics with the highest risks and reducing unnecessary antibiotic use are important strategies for prevention of CDI and subsequent recurrence. In addition, the recognition of the community as an important setting for onset of CDI presents a challenge and is an area for future research. [ABSTRACT FROM AUTHOR]

Objective: To estimate the association between vitamin D deficiency and bacterial vaginosis (BV) among nonpregnant HIV-infected and uninfected women. Methods: In a substudy of the Women's Interagency HIV Study, including women from Chicago and New York, the association between BV and vitamin D deficiency, demographics, and disease characteristics was tested using generalized estimating equations. Deficiency was defined as <20 ng/mL 25 (OH) vitamin D and insufficiency as >20 and ≤30 ng/mL. BV was defined by the Amsel criteria. Results: Among 602 observations of nonpregnant women (480 HIV infected and 122 uninfected), BV was found in 19%. Vitamin D deficiency was found in 59.4%, and insufficiency was found in 24.4%. In multivariable analysis, black race was the most significant predictor of BV (adjusted odds ratio [AOR] 5.90, (95% confidence interval [CI] 2.52-13.8). Vitamin D deficiency was independently associated with BV among HIV-infected women (AOR 3.12, 95% CI 1.16-8.38) but not among HIV-uninfected women. There was a negative linear correlation between vitamin D concentration and prevalence of BV in HIV-infected women ( r=−0.15, p=0.001). Conclusions: Vitamin D deficiency was very common in this cohort and significantly associated with BV among HIV-infected women. These preliminary findings suggest that further epidemiologic and mechanistic exploration of the relationship between vitamin D and BV in HIV-infected women is warranted. [ABSTRACT FROM AUTHOR]

Background The incidence of invasive fungal infections (IFI) and antifungal utilization is increasing in many healthcare settings. Little is known regarding antifungal stewardship strategies within broader antimicrobial stewardship programs (ASPs). This survey aimed to identify the use of antifungal stewardship at a diverse range of hospitals. Methods A cross-sectional electronic survey of the SHEA Research Network (SRN) was completed August–September 2018 by a physician or pharmacist ASP leader. The SRN is a consortium of >100 hospitals participating in multicenter healthcare epidemiology research projects. Survey questions pertained to various aspects of antifungal stewardship, including audit and feedback, laboratory testing, and surveillance. Chi-square tested associations between ASP and hospital characteristics and use of antifungal stewardship strategies. Results 45/111 (41%) facilities responded, including 10 international sites. Most facilities are academic medical centers (64.6%) and care for stem cell (73.3%) and solid-organ transplant (80.0%) patients. Most facilities have large, well established ASPs (60.0% > 5 members; 68.9% duration ≥6 years). 43 (95.6%) facilities use antifungal stewardship strategies in their ASP; most commonly prospective audit and feedback (33/43, 73.3%) performed by a pharmacist (23/33, 71.4%). Only half of ASPs (51.1%) create guidelines for IFI management. Most (71.1%) facilities offer rapid laboratory tests to diagnose IFI, but availability of PCR for fungal speciation and antifungal susceptibility testing varies (Figure 1). 29 ASPs (64.4%) perform surveillance of antifungal utilization, but only 9 (31.0%) report data to CDC's National Healthcare Safety Network (NHSN). ASP size, ASP duration, and presence of transplant populations were not associated with a higher likelihood of using antifungal stewardship strategies (P > 0.05 for all). Conclusion Use of antifungal stewardship strategies is high at SRN hospitals, but mainly involves audit and feedback. ASPs should be encouraged to disseminate guidelines for IFI management, to promote access to laboratory-based tests for rapid and accurate IFI diagnosis, and to perform surveillance for antifungal utilization with data reporting to NHSN. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]

Purpose We examined the prevalence of, and factors associated with, serious opioid-related adverse drug events (ORADEs) that led to an emergency department (ED) visit or hospitalization among patients with chronic gastrointestinal (GI) symptoms and disorders dually enrolled in the Department of Veterans Affairs (VA) and Medicare Part D. Methods In this retrospective cohort study, we used linked national patient-level data (April 1, 2011, to October 31, 2014) from the VA and Centers for Medicare and Medicaid Services to identify serious ORADEs among dually enrolled veterans with a chronic GI symptom or disorder. Outcome measures included serious ORADEs, defined as an ED visit attributed to an ORADE or a hospitalization where the principal or secondary reason for admission involved an opioid. We used multiple logistic regression models to determine factors independently associated with a serious ORADE. Results We identified 3,430 veterans who had a chronic GI symptom or disorder; were dually enrolled in the VA and Medicare Part D; and had a serious ORADE that led to an ED visit, hospitalization, or both. The period prevalence of having a serious ORADE was 2.4% overall and 4.4% among veterans with chronic opioid use (≥90 consecutive days). Veterans with serious ORADEs were more likely to be less than 40 years old, male, white, and to have chronic abdominal pain, functional GI disorders, chronic pancreatitis, or Crohn's disease. They were also more likely to have used opioids chronically and at higher daily doses. Conclusion There may be a considerable burden of serious ORADEs among patients with chronic GI symptoms and disorders. Future quality improvement efforts should target this vulnerable population. [ABSTRACT FROM AUTHOR]

Approximately 15% of casualties in the Afghanistan (Operation Enduring Freedom [OEF]) and Iraq (Operation Iraqi Freedom [OIF]) conflicts received mild traumatic brain injury (TBI). To identify Veterans who may benefit from treatment, the Department of Veterans Affairs (VA) implemented a national clinical reminder in 2007 to screen for TBI. Veterans who screen positive are referred for a comprehensive TBI evaluation. We conducted a national retrospective study of OIF/OEF Veterans receiving care at VA facilities between 2007 and 2008. We examined the association of the TBI screen with healthcare costs over a 12 mo period following the initial evaluation. Of the Veterans, 164,438 met inclusion criteria: 31,627 screened positive, 118,545 screened negative, and 14,266 received no TBI screening. Total healthcare costs of Veterans who screened positive, screened negative, or had no TBI screening were $9,610, $5,184, and $3,399, respectively (p < 0.001). Understanding these healthcare utilization and cost patterns will assist policy-makers to address the ongoing and future healthcare needs of these returning Veterans. [ABSTRACT FROM AUTHOR]