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Context There are concerns that policies aimed to prevent opioid misuse may unintentionally reduce access to opioids for patients at end-of-life. Objective We assessed trends in opioid prescribing among patients on discharge from the hospital to hospice care. Methods This was a retrospective cohort study among adult (age ≥18 years) patients discharged from a 544-576 bed, academic medical center to hospice care between January 1, 2010 to December 31, 2018. Study data were collected from a repository of patients’ electronic health record data. Our primary outcome was the frequency of opioid prescribing on discharge to hospice care. Our primary exposure was the calendar year of discharge. We also investigated non-opioid analgesic prescribing and stratified opioid prescribing trends by patient characteristics (e.g., demographics, cancer diagnosis, and location of hospice care). Results Among 2,648 discharges to hospice care, mean (standard deviation) age was 65.8 (16.0) years, 46.3% were female, and 58.7% had a cancer diagnosis. Opioid prescribing on discharge to hospice care decreased significantly from 91.2% (95% confidence interval (CI) = 87.1%–94.1%) in 2010 to 79.3% (95% CI = 74.3%–83.5%) in 2018 adjusting for age, sex, cancer diagnosis, and location of hospice care. Prescribing of non-opioid analgesic medications increased over the same time period. Conclusions We observed a statistically significant decreasing trend in opioid prescribing on discharge to hospice care. Further research should aim to confirm these findings and to identify opportunities to ensure optimal pain management among patients transitioning to hospice care. more...

BACKGROUND Little is known regarding differences between patients referred to hospice from different care locations. OBJECTIVE The objective this study was to describe the associations between hospice referral locations and hospice patient and admission characteristics. RESEARCH DESIGN Cross-sectional analysis of hospice administrative data. SUBJECTS Adult (age older than 18 y) decedents of a national, for-profit, hospice chain across 19 US states who died between January 1, 2012, and December 31, 2016. MEASURES Patients' primary hospice diagnosis, hospice length stay, and hospice care site. We also determined the frequency of opioid prescriptions with and without a bowel regimen on hospice admission. RESULTS Among 78,647 adult decedents, the mean age was 79.2 (SD=13.5) years, 56.4% were female, and 69.9% were a non-Hispanic White race. Most hospice referrals were from the hospital (51.9%), followed by the community (21.9%), nursing homes (17.4%), and assisted living (8.8%). Cancer (33.6%) was the most prevalent primary hospice diagnosis; however, this varied significantly between referral locations (P more...

PURPOSE Skilled nursing facility (SNF) residents are at increased risk for opioid-related harms. We quantified the frequency of opioid prescribing among patients discharged from an acute care hospital to SNFs. METHODS This was a retrospective cohort study among adult (≥18 years) inpatients discharged from a quaternary-care academic referral hospital in Portland, OR to a SNF between January 1, 2017 and December 31, 2018. Our primary outcome was receipt of an opioid prescription on discharge to a SNF. Our exposures included patient demographics (eg, age, sex), comorbid illnesses, surgical diagnosis related group (DRG), receiving opioids on the first day of the index hospital admission, and inpatient hospital length of stay. RESULTS Among 4374 patients discharged to a SNF, 3053 patients (70%) were prescribed an opioid on discharge. Among patients prescribed an opioid, 61% were over the age of 65 years, 50% were male, and 58% had a surgical Medicare severity diagnosis related group (MS-DRG). Approximately 70% of patients discharged to a SNF were prescribed an opioid on discharge, of which 68% were for oxycodone, and 52% were for ≥90 morphine milligram equivalents per day. Surgical DRG, diagnoses of cancer or chronic pain, last pain score, and receipt of an opioid on first day of the index hospital admission were independently associated with being prescribed an opioid on discharge to a SNF. CONCLUSION Opioids were frequently prescribed at high doses to patients discharged to a SNF. Efforts to improve opioid prescribing safety during this transition may be warranted. more...

Background/objectives Limited knowledge exists regarding sex differences in prescribing potentially inappropriate medications (PIMs) for various multimorbidity patterns. This study sought to determine sex differences in PIM prescribing in older adults with cardiovascular-metabolic patterns. Design Retrospective cohort study. Setting Health and Retirement Study (HRS) 2004-2014 interview data, linked to HRS-Medicare claims data annualized for 2005-2014. Study sample Six thousand three-hundred and forty-one HRS participants aged 65 and older with two and more chronic conditions. Measurements PIM events were calculated using 2015 American Geriatrics Society Beers Criteria. Multimorbidity patterns included: "cardiovascular-metabolic only," "cardiovascular-metabolic plus other physical conditions," "cardiovascular-metabolic plus mental conditions," and "no cardiovascular-metabolic disease" patterns. Logistic regression models were used to determine the association between PIM and sex, including interaction between sex and multimorbidity categories in the model, for PIM overall and for each PIM drug class. Results Women were prescribed PIMs more often than men (39.4% vs 32.8%). Overall, women had increased odds of PIM (Adj. odds ratio [OR] = 1.30, 95% confidence interval [CI]: 1.16-1.46). Women had higher odds of PIM than men with cardiovascular-metabolic plus physical patterns (Adj. OR = 1.25, 95% CI: 1.07-1.45) and cardiovascular-metabolic plus mental patterns (Adj. OR = 1.25, 95% CI: 1.06-1.48), and there were no sex differences in adults with a cardiovascular-metabolic only patterns (Adj. OR = 1.13, 95% CI: 0.79-1.62). Women had greater odds of being prescribed the following PIMs: anticholinergics, antidepressants, antispasmodics, benzodiazepines, skeletal muscle relaxants, and had lower odds of being prescribed pain drugs and sulfonylureas compared with men. Conclusion This study evaluated sex differences in PIM prescribing among adults with complex cardiovascular-metabolic multimorbidity patterns. The effect of sex varied across multimorbidity patterns and by different PIM drug classes. This study identified important opportunities for future interventions to improve medication prescribing among older adults at risk for PIM. more...

Background: Many older adults live with serious illness for years before their death. Nurse-led primary palliative care could improve their quality of life and ability to stay in their community. Objectives: To assess feasibility and acceptability of a nurse-led Transitional Palliative Care (TPC) program for older adults with serious illness. Methods: The study was a pilot trial of the TPC program in which registered nurses assisted patients with symptom management, communication with care providers, and advance care planning. Forty-one older adults with chronic conditions were enrolled in TPC or standard care groups. Feasibility was assessed through enrollment and attrition rates and degree of intervention execution. Acceptability was assessed through surveys and exit interviews with participants and intervention nurses. Results: Enrollment rate for those approached was 68%, and completion rate for those enrolled was 71%. The TPC group found the intervention acceptable and helpful and was more satisfied with care received than the control group. However, one-third of participants perceived that TPC was more than they needed, despite the number of symptoms they experienced and the burdensomeness of their symptoms. More than half of the participants had little to no difficulty participating in daily activities. Conclusion: This study demonstrated that the nurse-led TPC program is feasible, acceptable, and perceived as helpful. However, further refinement is needed in selection criteria to identify the population who would most benefit from primary palliative care before future test of the efficacy of this intervention. more...

BACKGROUND: Antibiotics are frequently prescribed to patients discharged to hospice care despite the shift in goals of care from curative to palliative therapy. OBJECTIVE: We aimed to better understand the clinical intentions for antibiotic prescribing on discharge from acute care to hospice care. DESIGN: Retrospective cohort study. SETTING: 544-bed academic, acute-care, tertiary referral hospital in Portland, Oregon. PARTICIPANTS: 149 adult (age ≥18 years) patients who received an outpatient prescription for antibiotics on discharge from an acute care hospital to hospice care between January 1, 2009 and December 31, 2011. MEASUREMENTS: We determined whether antibiotics were indicated for treatment of an active infection, palliative treatment, prophylaxis, and/or prescribed per family or patient preference. RESULTS: Antibiotics were prescribed to 17.6% (n=149) of patients discharged to hospice care over the 3-year study period. Antibiotics were most frequently prescribed for pneumonia (19.5%), urinary tract (18.9%), and gastrointestinal tract infections (17.0%). The explicit rationale for antibiotic prescription was only documented for 72 prescriptions (45.3%). For 84 (52.8%) patients, antibiotics were used to treat an active infection in the hospital. Among prescriptions with a documented rationale, 37.5% indicated that the intent was curative, 26.4% indicated that the intent was prophylaxis, and 22.2% indicated that the intent was to suppress an infection. Additionally, for 19.4% of prescriptions, patient and/or their family members specifically wanted to be treated with antibiotics. Only 9.7% of prescriptions specifically indicated that antibiotics were prescribed for palliative reasons. CONCLUSION: Antibiotics were frequently prescribed for treatment of active infection among patients discharged to hospice care. Further research is needed to document antibiotic benefits and risks and optimize medication management for patients at the end of life. more...

Optimal management of chronic medications for patients with life-limiting illness is uncertain. Medication deprescribing may improve outcomes in this population, but patient concerns regarding deprescribing are unclear.The aim of this study was to quantify the perceived benefits and concerns of statin discontinuation among patients with life-limiting illness.Baseline data from a multicenter, pragmatic clinical trial of statin discontinuation were used.Cognitively intact participants with a life expectancy of 1-12 months receiving statin medications for primary or secondary prevention were enrolled.Responses to a 9-item questionnaire addressing patient concerns about discontinuing statins were collected. We used Pearson chi-square tests to compare responses by primary life-limiting diagnosis (cancer, cardiovascular disease, other).Of 297 eligible participants, 58% had cancer, 8% had cardiovascular disease, and 30% other primary diagnoses. Mean (standard deviation) age was 72 (11) years. Fewer than 5% of participants expressed concern that statin deprescribing indicated physician abandonment. About one in five participants reported being told to take statins for the rest of their life (18%) or feeling that discontinuation represented prior wasted effort (18%). Many participants reported benefits of stopping statins, including spending less money on medications (63%), potentially stopping other medications (34%), and having a better quality of life (25%). More participants with cardiovascular disease as a primary diagnosis perceived that quality-of-life benefits related to statin discontinuation (52%) than participants with cancer (27%) or noncardiovascular disease diagnoses (27%) [p = 0.034].Few participants expressed concerns about discontinuing statins; many perceived potential benefits. Cardiovascular disease patients perceived greater potential positive impact from statin discontinuation. more...

OBJECTIVETo determine the scope, source, and mode of transmission of a multifacility outbreak of extensively drug-resistant (XDR)Acinetobacter baumannii.DESIGNOutbreak investigation.SETTING AND PARTICIPANTSResidents and patients in skilled nursing facilities, long-term acute-care hospital, and acute-care hospitals.METHODSA case was defined as the incident isolate from clinical or surveillance cultures of XDRAcinetobacter baumanniiresistant to imipenem or meropenem and nonsusceptible to all but 1 or 2 antibiotic classes in a patient in an Oregon healthcare facility during January 2012–December 2014. We queried clinical laboratories, reviewed medical records, oversaw patient and environmental surveillance surveys at 2 facilities, and recommended interventions. Pulsed-field gel electrophoresis (PFGE) and molecular analysis were performed.RESULTSWe identified 21 cases, highly related by PFGE or healthcare facility exposure. Overall, 17 patients (81%) were admitted to either long-term acute-care hospital A (n=8), or skilled nursing facility A (n=8), or both (n=1) prior to XDRA. baumanniiisolation. Interfacility communication of patient or resident XDR status was not performed during transfer between facilities. The rare plasmid-encoded carbapenemase geneblaOXA-237was present in 16 outbreak isolates. Contact precautions, chlorhexidine baths, enhanced environmental cleaning, and interfacility communication were implemented for cases to halt transmission.CONCLUSIONSInterfacility transmission of XDRA. baumanniicarrying the rare blaOXA-237was facilitated by transfer of affected patients without communication to receiving facilities.Infect Control Hosp Epidemiol2017;38:1335–1341 more...

ObjectiveTo quantify the frequency and outcomes of receiving an antibiotic prescription upon discharge from the hospital to long-term care facilities (LTCFs).DesignRetrospective cohort study.SettingA 576-bed, academic hospital in Portland, Oregon.PatientsAdult inpatients (≥18 years of age) discharged to an LTCF between January 1, 2012, and June 30, 2016.MethodsOur primary outcome was receiving a systemic antibiotic prescription upon discharge to an LTCF. We also quantified the association between receiving an antibiotic prescription and 30-day hospital readmission, 30-day emergency department (ED) visit, and Clostridium difficile infection (CDI) on a readmission or ED visit at the index facility within 60 days of discharge.ResultsAmong 6,701 discharges to an LTCF, 22.9% were prescribed antibiotics upon discharge. The most prevalent antibiotic classes prescribed were cephalosporins (20.4%), fluoroquinolones (19.1%), and penicillins (16.7%). The medical records of ~82% of patients included a diagnosis code for a bacterial infection on the index admission. Among patients prescribed an antibiotic upon discharge, the incidence of 30-day hospital readmission to the index facility was 15.9%, the incidence of 30-day ED visit at the index facility was 11.0%, and the incidence of CDI on a readmission or ED visit within 60 days of discharge was 1.6%. Receiving an antibiotic prescription upon discharge was significantly associated with 30-day ED visits (adjusted odds ratio [aOR], 1.2; 95% confidence interval [CI], 1.02–1.5) and with CDI within 60 days (aOR, 1.7; 95% CI, 1.02–2.8) but not with 30-day readmissions (aOR, 1.01; 95% CI, 0.9–1.2).ConclusionsAntibiotics were frequently prescribed upon discharge to LTCFs, which may be associated with increased risk of poor outcomes post discharge. more...

To quantify the frequency and type of medication decisions on discharge from the hospital to hospice care.Retrospective cohort study.A 544-bed academic tertiary care hospital in Portland, Oregon.A total of 348 adult patients (age ≥18 y) discharged to hospice care between January 1, 2010, and December 31, 2016.Data were collected from an electronic repository of medical record data and a manual review of patients' discharge summaries. Our outcomes of interest were the frequency and type of medication decisions documented in patients' discharge summaries. Medication decisions were categorized as continuation, continuation but with changes in dose, route of administration, and/or frequency, discontinuation, and initiation of new medications. We also collected data on the frequency of patient/family in the participation of medication-related decisions.Patients were prescribed a mean of 7.1 medications (standard deviation [SD] = 4.8) on discharge to hospice care. The most prevalent medications prescribed on discharge were strong opioids (82.5%), anxiolytics/sedatives (62.9%), laxatives (57.5%), antiemetics (54.3%), and nonopioid analgesics (45.4%). However, only 67.8% (213/341) of patients who were prescribed an opioid on discharge to hospice care were also prescribed a laxative. Discharging providers made a mean of 15.0 decisions (SD = 7.2) per patient of which 28.5% were to continue medications without changes, 6.7% were to continue medications with changes, 30.3% were to initiate new medications, and 34.5% were to discontinue existing medications. Patients and/or family members were involved in medication decisions during 21.6% of discharges; patients were involved in 15.2% of decisions.Patients averaged more than 15 medication decisions on discharge to hospice care. However, it was rarely documented that patients and/or their families participated in these decisions. J Am Geriatr Soc, 2019. more...

Posaconazole is used for prophylaxis for invasive fungal infections (IFIs) among patients with hematologic malignancies. We compared the incidence of breakthrough IFIs and early discontinuation between patients receiving delayed-release tablet and oral suspension formulations of posaconazole. This was a retrospective cohort study of patients receiving posaconazole between 1 January 2010 and 30 June 2016. We defined probable or proven breakthrough IFIs using the European Organization for Research and Treatment of Cancer (EORTC) criteria. Overall, 547 patients received 860 courses of posaconazole (53% received the oral suspension and 48% received the tablet); primary indications for prophylaxis were acute myeloid leukemia (69%), graft-versus-host disease (18%), and myelodysplastic syndrome (3%). There were no significant differences in demographics or indications between patients receiving the different formulations. The incidence and incidence rate of probable or proven IFIs were 1.6% and 3.2 per 10,000 posaconazole days, respectively. There was no significant difference in the rate of IFIs between suspension courses (2.8 per 10,000 posaconazole days) and tablet courses (3.7 per 10,000 posaconazole days) (rate ratio = 0.8, 95% confidence interval [CI] = 0.3 to 2.3). Of the 14 proven or probable cases of IFI, 8/14 had posaconazole serum concentrations measured, and the concentrations in 7/8 were above 0.7 μg/ml. Posaconazole was discontinued early in 15.5% of courses; however, the frequency of discontinuation was also not significantly different between the tablet (16.5%) and oral suspension (14.6%) formulations (95% CI for difference = -0.13 to 0.06). In conclusion, the incidence of breakthrough IFIs was low among patients receiving posaconazole prophylaxis and not significantly different between patients receiving the tablet formulation and those receiving the oral suspension formulation. more...

There are no guidelines for antithrombotic therapy on admission to hospice care. Antithrombotic therapy may offer some benefit in these patients, but is also associated with well-described risks.We quantified the frequency and characteristics of patients prescribed antithrombotic therapy on discharge from acute care to hospice care.Retrospective cohort study. Settings/Subjects: Adult (age = 21 years) patients discharged from acute care to hospice care between January 1, 2010 and June 30, 2014.Our primary outcome of interest was receiving an outpatient prescription for antithrombotic therapy on discharge to hospice care.Among 1141 eligible patients, 77 (6.7%) patients received a prescription for antithrombotic therapy on discharge to hospice care, most frequently, aspirin (57.1%), enoxaparin (26.0%), and warfarin (20.8%). Patients actively treated for deep vein thromboembolism or pulmonary embolism, or with a history of atrial fibrillation or aortic/mitral valve replacement were significantly more likely to receive antithrombotic therapy. Patients with a history of cancer, cerebrovascular disease, or liver disease were significantly less likely to receive antithrombotic therapy (p 0.05 for all). Among patients who received antithrombotic therapy, 22% were not receiving antithrombotic therapy before the index admission. Among patients previously receiving antithrombotic therapy, 55% continued on the same medication, of which 54.5% did not have any documented rationale for continuation.Prescriptions for antithrombotic therapy were infrequent and often lacked a documented rationale. Further research is needed on the safety and effectiveness of antithrombotic therapy in hospice care and what drives current medication decisions in the absence of these data. more...

Background.Antibiograms have effectively improved antibiotic prescribing in acute-care settings; however, their effectiveness in skilled nursing facilities (SNFs) is currently unknown.Objective.To develop SNF-specific antibiograms and identify opportunities to improve antibiotic prescribing.Design and Setting.Cross-sectional and pretest-posttest study among residents of 3 Maryland SNFs.Methods.Antibiograms were created using clinical culture data from a 6-month period in each SNF. We also used admission clinical culture data from the acute care facility primarily associated with each SNF for transferred residents. We manually collected all data from medical charts, and antibiograms were created using WHONET software. We then used a pretest-posttest study to evaluate the effectiveness of an antibiogram on changing antibiotic prescribing practices in a single SNF. Appropriate empirical antibiotic therapy was defined as an empirical antibiotic choice that sufficiently covered the infecting organism, considering antibiotic susceptibilities.Results.We reviewed 839 patient charts from SNF and acute care facilities. During the initial assessment period, 85% of initial antibiotic use in the SNFs was empirical, and thus only 15% of initial antibiotics were based on culture results. Fluoroquinolones were the most frequently used empirical antibiotics, accounting for 54.5% of initial prescribing instances. Among patients with available culture data, only 35% of empirical antibiotic prescribing was determined to be appropriate. In the single SNF in which we evaluated antibiogram effectiveness, prevalence of appropriate antibiotic prescribing increased from 32% to 45% after antibiogram implementation; however, this was not statistically significant (P = .32).Conclusions.Implementation of antibiograms may be effective in improving empirical antibiotic prescribing in SNFs. more...

BACKGROUND Little is known regarding the prevalence or risk factors for non-comprehension and non-compliance with discharge instructions among older adults.

Objectives: To quantify the risk of 30-day unplanned hospital readmission in adults aged 65 and older with depressive symptoms. Design: Prospective cohort study. Setting: University of Maryland Medical Center. Participants: Individuals aged 65 and older admitted between July 1, 2011, and August 9, 2012, to the general medical and surgical units and followed for 31 days after hospital discharge (N = 750). Measurements: Primary exposure was depressive symptoms at admission, defined as a score of 6 or more on the 15-item Geriatric Depression Scale. Primary outcome was unplanned 30-day hospital readmission, defined as an unscheduled overnight stay at any inpatient facility not occurring in the emergency department. Results: Prevalence of depressive symptoms was 19% and incidence of 30-day unplanned hospital readmission was 19%. Depressive symptoms were not significantly associated with hospital readmission (relative risk (RR) = 1.20, 95% confidence interval (CI) = 0.83�1.72). Age, Charlson Comorbidity Index score, and number of hospitalizations within the past 6 months were significant predictors of unplanned 30-day hospital readmission. Conclusion: Although not associated with hospital readmission, depressive symptoms were associated with other poor outcomes and may be underdiagnosed in hospitalized older adults. Hospitals interested in reducing readmission should focus on older adults with more comorbid illness and recent hospitalizations. more...

Context Antibiotic prescription in hospice patients is complicated by the focus on palliative rather than curative care and concerns regarding increasing antibiotic resistance. Objectives To estimate the antibiotic use in a national sample of hospice patients and identify facility and patient characteristics associated with antibiotic use in this population. Methods This was an analysis of data from the 2007 National Home and Hospice Care Survey, a nationally representative sample of U.S. hospice agencies. We included data from 3884 patients who died in hospice care. The primary outcome measure was prevalence of antibiotic use in the last seven days of life. Diagnoses, including potential infectious indications for antibiotic use, were defined using International Classification of Diseases, Ninth Revision (ICD-9) codes. Chi-squared tests and t-tests were used to quantify associations of patient and facility characteristics with antibiotic use. Results During the last seven days of life, 27% (95% CI: 24%-30%) of patients received at least one antibiotic and 1.3% (95% CI: 0.7%-2.0%) received three or more antibiotics. Among patients who received at least one antibiotic, 15% (95% CI: 10%-20%) had a documented infectious diagnosis compared with 9% (95% CI: 7%-11%), who had an infectious diagnosis but received no antibiotics. Conclusion In this nationally representative sample, 27% of hospice patients received an antibiotic during the last seven days of life, most without a documented infectious diagnosis. Further research is needed to elucidate the role of antibiotics in this patient population to maintain palliative care goals while reducing unnecessary antibiotic use. more...

Extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae strains are increasing in prevalence worldwide. Carbapenem antibiotics are used as a first line of therapy against ESBL-producing Enterobacteriaceae . We examined a cohort of critical care patients for gastrointestinal colonization with carbapenem-resistant ESBL-producing strains (CR-ESBL strains). We cultured samples from this cohort of patients for ESBL-producing Klebsiella spp. and Escherichia coli and then tested the first isolate from each patient for susceptibility to imipenem, doripenem, meropenem, and ertapenem. Multilocus sequence typing was performed on isolates that produced an ESBL and that were carbapenem resistant. Among all patients admitted to an intensive care unit (ICU), 4% were positive for an ESBL-producing isolate and 0.64% were positive for a CR-ESBL strain on surveillance culture. Among the first ESBL-producing E. coli and Klebsiella isolates from the patients' surveillance cultures, 11.2% were carbapenem resistant. Sequence type 14 (ST14), ST15, ST42, and ST258 were the dominant sequence types detected in this cohort of patients, with ST15 and ST258 steadily increasing in prevalence from 2006 to 2009. Patients colonized by a CR-ESBL strain were significantly more likely to receive antipseudomonal and anti-methicillin-resistant Staphylococcus aureus (anti-MRSA) therapy prior to ICU admission than patients colonized by carbapenem-susceptible ESBL-producing strains. They were also significantly more likely to have received a cephalosporin or a carbapenem antibiotic than patients colonized by carbapenem-susceptible ESBL-producing strains. In conclusion, in a cohort of patients residing in intensive care units within the United States, we found that 10% of the isolates were resistant to at least one carbapenem antibiotic. The continued emergence of carbapenem-resistant ESBL-producing strains is of significant concern, as infections due to these organisms are notoriously difficult to treat. more...

Objective.Hospital readmissions are a current target of initiatives to reduce healthcare costs. This study quantified the association between having a clinical culture positive for 1 of 3 prevalent hospital-associated organisms and time to hospital readmission.Design.Retrospective cohort study.Patients and Setting.Adults admitted to an academic, tertiary care referral center from January 1, 2001, through December 31, 2008.Methods.The primary exposure of interest was a clinical culture positive for methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), or Clostridium difficile obtained more than 48 hours after hospital admission during the index hospital stay. The primary outcome of interest was time to readmission to the index facility. Multivariable Cox proportional hazards models were used to model the adjusted association between positive clinical culture result and time to readmission and to calculate hazard ratios (HRs) and 95% confidence intervals (CIs).Results.Among 136,513 index admissions, the prevalence of hospital-associated positive clinical culture result for 1 of the 3 organisms of interest was 3%, and 35% of patients were readmitted to the index facility within 1 year after discharge. Patients with a positive clinical culture obtained more than 48 hours after hospital admission had an increased hazard of readmission (HR, 1.40; 95% CI, 1.33–1.46) after adjusting for age, sex, index admission length of stay, intensive care unit stay, Charlson comorbidity index, and year of hospital admission.Conclusions.Patients with healthcare-associated infections may be at increased risk of hospital readmission. These findings may be used to impact health outcomes after discharge from the hospital and to encourage better infection prevention efforts. more...

Accessory gene regulator ( agr ) dysfunction in Staphylococcus aureus has been associated with a longer duration of bacteremia. We aimed to assess the independent association between agr dysfunction in S. aureus bacteremia and 30-day in-hospital mortality. This retrospective cohort study included all adult inpatients with S. aureus bacteremia admitted between 1 January 2003 and 30 June 2007. Severity of illness prior to culture collection was measured using the modified acute physiology score (APS). agr dysfunction in S. aureus was identified semiquantitatively by using a δ-hemolysin production assay. Cox proportional hazard models were used to measure the association between agr dysfunction and 30-day in-hospital mortality, statistically adjusting for patient and pathogen characteristics. Among 814 patient admissions complicated by S. aureus bacteremia, 181 (22%) patients were infected with S. aureus isolates with agr dysfunction. Overall, 18% of patients with agr dysfunction in S. aureus died, compared to 12% of those with functional agr in S. aureus ( P = 0.03). There was a trend toward higher mortality among patients with S. aureus with agr dysfunction (adjusted hazard ratio [HR], 1.34; 95% confidence interval [CI], 0.87 to 2.06). Among patients with the highest APS (scores of >28), agr dysfunction in S. aureus was significantly associated with mortality (adjusted HR, 1.82; 95% CI, 1.03 to 3.21). This is the first study to demonstrate an independent association between agr dysfunction and mortality among severely ill patients. The δ-hemolysin assay examining agr function may be a simple and inexpensive approach to predicting patient outcomes and potentially optimizing antibiotic therapy. more...

Objective.To assess risk factors for methicillin-resistant Staphylococcus aureus (MRSA) acquisition among extended care residents focusing on level of care (residential vs rehabilitation) and room placement with an MRSA-positive resident.Design.Prospective cohort study.Setting.Extended care units at 2 healthcare systems in Maryland.Participants.Four hundred forty-three residents with no history of MRSA and negative MRSA surveillance cultures of the anterior nares and areas of skin breakdown at enrollment.Methods.Follow-up cultures were collected every 4 weeks and/or at discharge for a period of 12 weeks. Study data were collected by a research nurse from the medical staff and the electronic medical records. Cox proportional hazards modeling was used to calculate adjusted hazards ratios (aHRs) and 95% confidence intervals (CIs).Results.Residents in rehabilitation care had 4-fold higher risk of MRSA acquisition compared with residents in residential care (hazard ratio [HR], 4. [95% CI, 2.2-8.8]). Being bedbound was significantly associated with MRSA acquisition in both populations (residential care, aHR, 4.3 [95% CI, 1.5-12.2]; rehabilitation care, aHR, 4.8 [95% CI, 1.2-18.7]). Having an MRSA-positive roommate was not significantly associated with acquisition in either population (residential care, aHR, 1.4 [95% CI, 0.5-3.9]; rehabilitation care, aHR, 0.5 [95% CI, 0.1-2.2]); based on concordant spa typing, only 2 of 8 residents who acquired MRSA and had room placement with an MRSA-positive resident acquired their MRSA isolate from their roommate.Conclusion.Residents in rehabilitation care appear at higher risk and have different risk factors for MRSA acquisition compared to those in residential care. more...

The present study aimed to determine the frequency of methicillin-resistant Staphylococcus aureus (MRSA)-positive clinical culture among hospitalized adults in different risk categories of a targeted MRSA active surveillance screening program and to assess the utility of screening in guiding empiric antibiotic therapy. We completed a prospective cohort study in which all adults admitted to non-intensive-care-unit locations who had no history of MRSA colonization or infection received targeted screening for MRSA colonization upon hospital admission. Anterior nares swab specimens were obtained from all high-risk patients, defined as those who self-reported admission to a health care facility within the previous 12 months or who had an active skin infection on admission. Data were analyzed for the subcohort of patients in whom an infection was suspected, determined by (i) receipt of antibiotics within 48 h of admission and/or (ii) the result of culture of a sample for clinical analysis (clinical culture) obtained within 48 h of admission. Overall, 29,978 patients were screened and 12,080 patients had suspected infections. A total of 46.4% were deemed to be at high risk on the basis of the definition presented above, and 11.1% of these were MRSA screening positive (colonized). Among the screening-positive patients, 23.8% had a sample positive for MRSA by clinical culture. Only 2.4% of patients deemed to be at high risk but found to be screening negative had a sample positive for MRSA by clinical culture, and 1.6% of patients deemed to be at low risk had a sample positive for MRSA by clinical culture. The risk of MRSA infection was far higher in those who were deemed to be at high risk and who were surveillance culture positive. Targeted MRSA active surveillance may be beneficial in guiding empiric anti-MRSA therapy. more...

We performed a retrospective cohort study (n = 129) to assess whether residents of extended care facilities who were initially colonized or infected with the methicillin-resistant Staphylococcus aureus (MRSA) strain USA300 were less likely to have prolonged colonization than were residents colonized or infected with other MRSA strains. We found no difference in prolonged colonization (adjusted odds ratio, 1.1 [95% confidence interval, 0.5–2.4]). more...

Objectives: To compare the proportion of antimicrobial-resistant strains among bacterial isolates from younger and older hospital patients and to quantify changes in the proportion of antimicrobialresistant strains in both groups over time. Patients and methods: A retrospective analysis of microbiology data from two centres in Maryland and Chicago was performed. Adult hospital inpatients with positive clinical cultures for specific antimicrobial-resistant bacterial pathogens between 1999 and 2005 (55427 isolates) were included. The proportions of isolates not susceptible to specific antimicrobial agents were compared between patients � 65 and more...

Background Patients in long-term acute care (LTAC) facilities often have many known risk factors for acquisition of antibiotic-resistant bacteria. However, the prevalence of resistance in these facilities has not been well described. Methods We performed a single-day, point-prevalence study of a 180-bed, university-affiliated LTAC facility in Baltimore to assess the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) and Acinetobacter baumannii in the anterior nares, perirectal area, sputum, and wounds. Results Among the 147 patients evaluated, we found a high prevalence of colonization by both MRSA (28%) and A baumannii (30%). Of the A baumannii isolates, 90% were susceptible to imipenem and 92% were susceptible to ampicillin-sulbactam. No isolates were resistant to both imipenem and ampicillin-sulbactam. Conclusion The high prevalence of resistance found in this study supports the need for increased surveillance of patients in the LTAC environment. The fact that these patients are often frequently transferred to tertiary care facilities also supports the need for coordination and collaboration among facilities within the same health care system and the broader geographic area. more...

Although a growing number of studies have found a relationship between delayed appropriate antibiotic therapy and mortality, few have attempted to quantify the temporal association between delayed appropriate antibiotic therapy and mortality. This study was designed to measure the elapsed time associated with an increased risk of 30-day mortality among patients with Pseudomonas aeruginosa bacteremia. The retrospective cohort study was conducted among immunocompetent, adult patients with P. aeruginosa bacteremia onset at least 2 days after hospital admission between 1 January 2001 and 30 September 2006. Classification and regression tree analysis (CART) was used to identify the delay in appropriate antibiotic therapy that was associated with an increased risk of 30-day mortality. During the study period, 100 patients met the inclusion criteria. The CART-derived breakpoint between early and delayed treatment was 52 h. The delayed treatment group experienced a >2-fold significant increase in 30-day mortality compared to the early treatment group (44 and 19%, respectively, P = 0.008). Delayed appropriate therapy of >52 h (odds ratio [OR] = 4.1; 95% confidence interval [CI] 1.2 to 13.9, P = 0.03) was independently associated with 30-day mortality in the multivariate analysis. Antibiotic resistance ≥3 classes (adjusted OR [AOR] = 4.6; 95% CI = 1.9 to 11.2, P = 0.001) and chronic obstructive pulmonary disease (AOR = 5.4; 95% CI = 1.5 to 19.7, P = 0.01) were independently associated with delayed appropriate therapy of >52 h. The data strongly suggest that delaying appropriate therapy for approximately 2 days significantly increases the risk of 30-day mortality in patients with P. aeruginosa bloodstream infections. more...

Comorbidity is a known risk factor for antibiotic-resistant bacterial infections. Although aggregate comorbidity measures are useful in epidemiologic research, none of the existing measures was developed for use with this outcome. This study compared the utility of two comorbidity measures, the Charlson Comorbidity Index and the Chronic Disease Score, in assessing the comorbidity-attributable risk of nosocomial infections with methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant enterococci (VRE). Two case-control studies were conducted at the University of Maryland Medical System in Baltimore, Maryland. Cases were inpatients with a first positive clinical culture of MRSA or VRE at least 48 hours postadmission (July 1, 1998-July 1, 2001). Three inpatient controls were randomly selected per case. The MRSA study included 2,164 patients, and the VRE study included 1,948. The scores' discrimination and calibration were measured by using the c statistic and Hosmer-Lemeshow chi-square test. The Charlson Comorbidity Index (c = 0.653) and Chronic Disease Score (c = 0.608) were similar discriminators of MRSA and VRE (c = 0.670 and c = 0.647, respectively). Calibration of the scores was poor for both outcomes (p < 0.05). A revised comorbidity measure specific to resistant infections would likely provide a better assessment of the comorbidity-attributable risk of antibiotic-resistant infections. more...

The use of antibiotics is common in hospice care despite limited evidence that it improves symptoms or quality of life. Patients receiving antibiotics upon discharge from a hospital may be more likely to continue use following transition to hospice care despite a shift in the goals of care. We quantified the frequency and characteristics for receiving a prescription for antibiotics on discharge from acute care to hospice care. This was a cross-sectional study among adult inpatients (≥18 years old) discharged to hospice care from Oregon Health & Science University (OHSU) from 1 January 2010 to 31 December 2012. Data were collected from an electronic data repository and from the Department of Care Management. Among 62,792 discharges, 845 (1.3%) patients were discharged directly to hospice care (60.0% home and 40.0% inpatient). Most patients discharged to hospice were >65 years old (50.9%) and male (54.6%) and had stayed in the hospital for ≤7 days (56.6%). The prevalence of antibiotic prescription upon discharge to hospice was 21.1%. Among patients discharged with an antibiotic prescription, 70.8% had a documented infection during their index admission. Among documented infections, 40.3% were bloodstream infections, septicemia, or endocarditis, and 38.9% were pneumonia. Independent risk factors for receiving an antibiotic prescription were documented infection during the index admission (adjusted odds ratio [AOR] = 7.00; 95% confidence interval [95% CI] = 4.68 to 10.46), discharge to home hospice care (AOR = 2.86; 95% CI = 1.92 to 4.28), and having a cancer diagnosis (AOR = 2.19; 95% CI = 1.48 to 3.23). These data suggest that a high proportion of patients discharged from acute care to hospice care receive an antibiotic prescription upon discharge. more...

We conducted a prospective cohort study of non–critically ill patients admitted to a tertiary care center between December 2003 and September 2004 and obtained perirectal samples at hospital admission to determine the prevalence of Acinetobacter baumannii . A baumannii was isolated from 1 of 555 cultures (0.18%); no multidrug-resistant A baumannii was identified. Interventions aimed at early identification of A baumannii –colonized patients may not benefit by widely targeting non–critically ill patients on hospital admission. more...

Purpose The impact of a pharmacy-managed program for providing education and discharge instructions for patients with heart failure (HF) was evaluated. Methods A before-and-after quasiexperimental design was used to quantify the effect of a pharmacist-managed HF medication education and discharge instruction program on the incidence of 30-day readmission rates and adherence to targeted Joint Commission core measures for HF (the provision of discharge instructions and the prescribing of an angiotensin-converting-enzyme inhibitor [ACEI]/angiotensin II receptor blocker [ARB] at discharge or documentation of the reason if therapy was not prescribed). Adult patients admitted to Oregon Health and Science University’s cardiology unit with systolic HF exacerbation as their primary diagnosis between December 2010 and March 2011 were included. Throughout patients’ hospitalization, the pharmacist collaborated with the multidisciplinary team to make treatment and monitoring recommendations; provided discharge medication reconciliation, discharge medication recommendations, and discharge instructions; answered patient-specific questions; and gave the patient a complete discharge medication list. Results The study enrolled 35 patients and compared results against a historical control group of 115 patients. The frequency of discharge counseling increased significantly ( p = 0.007), as did the rate of ACEI/ARB prescribing at discharge ( p = 0.02). Both 30-day all-cause and HF-related readmissions were reduced compared with baseline ( p = 0.02 and p = 0.11, respectively). Conclusion Pharmacist involvement in medication reconciliation and discharge counseling for HF patients was associated with a significant increase in adherence with the Joint Commission’s core measures, a significant reduction in 30-day all-cause readmissions, and a positive effect on patient satisfaction. more...

Patients with dementia constitute an increasing proportion of hospice enrollees, yet little is known about the quality of hospice care for this population. The aim of this study was to quantify differences in quality of care measures between hospice patients with and without dementia. Design: Cross-sectional analysis of data. Setting: 2007 National Home and Hospice Care Survey. Participants: Four thousand seven hundred eleven discharges from hospice care. Measurements: A primary diagnosis of dementia at discharge was defined according to International Classification of Diseases, Ninth Revision, codes (290.0�290.4x, 294.0, 294.1, 294.8, 331.0�331.2, 331.7, and 331.8). Quality-of-care measures included enrollment in hospice in the last 3 days of life, receiving tube feeding, depression, receiving antibiotics, lack of advanced directive or do not resuscitate order, Stage II or greater pressure ulcers, emergency care, lack of continuity of residence, and a report of pain at last assessment. Results: Four hundred fifty (9.5%) individuals were discharged with a primary diagnosis of dementia. In multivariable analysis, individuals with dementia were more likely to receive tube feeding (odds ratio (OR) = 2.6, 95% confidence interval (CI) = 1.4�4.5) and to have greater continuity of residence (OR = 1.8, 95% CI = 1.1�3.0) than other individuals in hospice and less likely to have a report of pain at last assessment (OR = 0.6, 95% CI = 0.3�0.9). Conclusions: The majority of quality-of-care measures examined did not differ between individuals in hospice with and without dementia. Use of tube feeding in hospice care and methods of pain assessment and treatment in individuals with dementia should be considered as potential quality-of-care measures. more...

Objective.To quantify the association between admission to an intensive care unit (ICU) room most recently occupied by a patient positive for extended-spectrumβ-lactamase (EBSL)-producing gram-negative bacteria and acquisition of infection or colonization with that pathogen.Design.Retrospective cohort study.Setting and Patients.The study included patients admitted to medical and surgical ICUs of an academic medical center between September 1, 2001, and June 30, 2009.Methods.Perianal surveillance cultures were obtained at admission to the ICU, weekly, and at discharge from the ICU. Patients were included if they had culture results that were negative for ESBL-producing gram-negative bacteria at ICU admission and had an ICU length of stay longer than 48 hours. Pulsed-field gel electrophoresis (PFGE) was performed on ESBL-positive isolates from patients who acquired the same bacterial species (eg,Klebsiellaspecies orEscherichia coli) as the previous room occupant.Results.Among 9, 371 eligible admissions (7, 651 unique patients), 267 (3%) involved patients who acquired an ESBL-producing pathogen in the ICU; of these patients, 32 (12%) were hospitalized in a room in which the prior occupant had been positive for ESBL. Logistic regression results suggested that the prior occupant's ESBL status was not significantly associated with acquisition of an ESBL-producing pathogen (adjusted odds ratio, 1.39 [95% confidence interval, 0.94-2.08]) after adjusting for colonization pressure and antibiotic exposure in the ICU. PFGE results suggested that 6 (18%) of 32 patients acquired a bacterial strain that was the same as or closely related to the strain obtained from the prior occupant.Conclusions.These data suggest that environmental contamination may not play a substantial role in the transmission of ESBL-producing pathogens among ICU patients. Intensifying environmental decontamination may be less effective than other interventions in preventing transmission of ESBL-producing pathogens. more...

Patients with serious mental illness (SMI), particularly those with other chronic illnesses, may be vulnerable to unplanned hospital readmission. The authors hypothesized that SMI would be associated with increased 30-day hospital readmission in a cohort of adult patients with comorbid diabetes admitted to a tertiary care facility from 2005 to 2009. SMI was defined by International Classification of Diseases, Ninth Revision, discharge diagnosis codes for schizophrenia, schizoaffective, bipolar, manic, or major depressive disorders, or other psychosis. The primary outcome was 30-day readmission to the index hospital. Among 26 878 eligible admissions, the prevalence of SMI was 6% and the incidence of 30-day hospital admission was 16%. Among patients aged more...

Risk factors for development of intestinal colonization by imipenem-resistant Pseudomonas aeruginosa (IRPA) may differ between those who acquire the organism via patient-to-patient transmission versus by antibiotic selective pressure. The aim of this study was to quantify potential risk factors for the development of IRPA not due to patient-to-patient transmission. more...

Background Appropriate empiric therapy, antibiotic therapy with in vitro activity to the infecting organism given prior to confirmed culture results, may improve Staphylococcus aureus outcomes. We aimed to measure the clinical impact of appropriate empiric antibiotic therapy on mortality, while statistically adjusting for comorbidities, severity of illness and presence of virulence factors in the infecting strain. Methodology We conducted a retrospective cohort study of adult patients admitted to a tertiary-care facility from January 1, 2003 to June 30, 2007, who had S. aureus bacteremia. Time to appropriate therapy was measured from blood culture collection to the receipt of antibiotics with in vitro activity to the infecting organism. Cox proportional hazard models were used to measure the association between receipt of appropriate empiric therapy and in-hospital mortality, statistically adjusting for patient and pathogen characteristics. Principal Findings Among 814 admissions, 537 (66%) received appropriate empiric therapy. Those who received appropriate empiric therapy had a higher hazard of 30-day in-hospital mortality (Hazard Ratio (HR): 1.52; 95% confidence interval (CI): 0.99, 2.34). A longer time to appropriate therapy was protective against mortality (HR: 0.79; 95% CI: 0.60, 1.03) except among the healthiest quartile of patients (HR: 1.44; 95% CI: 0.66, 3.15). Conclusions/Significance Appropriate empiric therapy was not associated with decreased mortality in patients with S. aureus bacteremia except in the least ill patients. Initial broad antibiotic selection may not be widely beneficial. more...

Background.The anterior nares are the most sensitive single site for detecting methicillin-resistantStaphylococcus aureus(MRSA) colonization. Colonization patterns of USA300 MRSA colonization are unknown.Objectives.To assess whether residents of extended care facilities who are colonized with USA300 MRSA have different nares or skin colonization findings, compared with residents who are colonized with non-USA300 MRSA strains.Methods.The study population included residents of 5 extended care units in 3 separate facilities who had a recent history of MRSA colonization. Specimens were obtained weekly for surveillance cultures from the anterior nares, perineum, axilla, and skin breakdown (if present) for 3 weeks. MRSA isolates were categorized as USA300 MRSA or non-USA300 MRSA.Results.Of the 193 residents who tested positive for MRSA, 165 were colonized in the anterior nares, and 119 were colonized on their skin. Eighty-four percent of USA300 MRSA-colonized residents had anterior nares colonization, compared with 86% of residents colonized with non-USA300 MRSA (P= .80). Sixty-six percent of USA300 MRSA–colonized residents were colonized on the skin, compared with 59% of residents colonized with non-USA300 MRSA (P= .30).Conclusions.Colonization patterns of USA300 MRSA and non-USA300 MRSA are similar in residents of extended care facilities. Anterior nares cultures will detect most—but not all—people who are colonized with MRSA, regardless of whether it is USA300 or non-USA300 MRSA. more...

This 5-year study of 25,378 hospitalizations measured the utility of infection control documentation of prior methicillin-resistant Staphylococcus aureus (MRSA) colonization or infection for the optimization of empirical antibiotic therapy. Documented prior MRSA colonization or infection was predictive of subsequent MRSA infections (odds ratio, 4.05). Physicians appear to use this documentation when prescribing empirical therapy for suspected bacteremia. more...

Background.Severity of illness is an important confounder in outcome studies involving infectious diseases. However, it is unclear whether the time at which severity of illness is measured is important.Methods.We performed a retrospective study of 328 episodes of gram-negative bacteremia in adult patients to assess the impact of the time of measurement of severity of illness on the association between empirical antimicrobial therapy received and in-hospital mortality. Using a modified Acute Physiology Score (APS), severity of illness was measured at 2 time points: (1) hospital admission and (2) 24 hours before the first culture-positive blood sample was collected. Multivariate logistic regression was used to estimate the impact of adjusting for the APS on the relationship between empirical therapy received (ie, the exposure) and in-hospital mortality (ie, the outcome).Results.The mean APS ( ± standard deviation) of patients with bacteremia increased during their hospital stay (from 19.2 ± 11.6 at admission to 24.2 ± 13.6 at the second time point; P < .01). When examining the association between empirical antimicrobial therapy received and in-hospital mortality, and controlling for the APS, there was a trend toward a decreased impact of appropriate therapy received on in-hospital mortality. The unadjusted odds ratio (OR) for the association between appropriate therapy received and in-hospital mortality was 0.83 (95% confidence interval [CI], 0.51-1.34). After controlling for the APS at admission, this association was attenuated (OR, 0.94 [95% CI, 0.57-1.55]), and when a change in the APS was also included in the multivariate logistic regression model, the association was further attenuated (OR, 0.99 [95% CI, 0.58-1.69]).Conclusions.The magnitude of the association between appropriate antimicrobial therapy received and in-hospital mortality among patients with gram-negative bacteremia was sensitive to the timing of adjustment for severity of illness. more...

The impact of appropriate empirical antimicrobial therapy for Pseudomonas aeruginosa bacteremia on patient outcomes has not been clearly established. We assessed the effect of appropriate empirical therapy on in-hospital mortality and length of stay (LOS) among patients with P. aeruginosa bacteremia. This was a retrospective cohort study of inpatients with a positive blood culture for P. aeruginosa between January 2001 and June 2005. Empirical therapy was defined as appropriate if the patient received an antibiotic the organism was susceptible to between 8 h before culture collection and the time the susceptibility results were available. The severity of the illness was measured 24 h before culture collection. The data were analyzed using logistic regression (in-hospital mortality) and linear regression (LOS). Overall, there were 167 episodes of P. aeruginosa bacteremia, 123 (86%) of which received appropriate empirical antibiotics. Sixty-one patients died (36.5%). The median time from culture collection to susceptibility results was 3.4 days. After we adjusted for age, severity of illness, and time at risk, we found that the appropriate empirical therapy was not significantly associated with mortality (odds ratio = 0.96; 95% confidence interval = 0.31 to 2.93). There was a 7% reduction in the mean LOS for patients who had received appropriate therapy at the time susceptibility results were available compared to those who did not ( P = 0.74). These data suggest that the use of appropriate empirical therapy, i.e., before susceptibility results are known may not be as critical to patient outcomes as other studies have suggested. more...

Despite the increasing prevalence of multiple-drug-resistant (MDR) Pseudomonas aeruginosa , the factors predictive of MDR have not been extensively explored. We sought to examine factors predictive of MDR among patients with P. aeruginosa respiratory tract infections and to develop a tool to estimate the probability of MDR among such high-risk patients. This was a single-site, case-control study of patients with P. aeruginosa respiratory tract infections. Multiple-drug resistance was defined as resistance to four or more antipseudomonal antimicrobial classes. Clinical data on demographics, antibiotic history, and microbiology were collected. Classification and regression tree analysis (CART) was used to identify the duration of antibiotic exposure associated with MDR P. aeruginosa . Log-binomial regression was used to model the probability of MDR P. aeruginosa . Among 351 P. aeruginosa -infected patients, the proportion of MDR P. aeruginosa was 35%. A significant relationship between prior antibiotic exposure and MDR P. aeruginosa was found for all of the antipseudomonal antibiotics studied, but the duration of prior exposure associated with MDR varied between antibiotic classes; the shortest prior exposure duration was observed for carbapenems and fluoroquinolones, and the longest duration was noted for cefepime and piperacillin-tazobactam. Within the final model, the predicted MDR P. aeruginosa likelihood was most dependent upon length of hospital stay, prior culture sample collection, and number of CART-derived prior antibiotic exposures. A history of a prolonged hospital stay and exposure to antipseudomonal antibiotics predicts multidrug resistance among patients with P. aeruginosa respiratory tract infections at our institution. Identifying these risk factors enabled us to develop a prediction tool to assess the risk of resistance and thus guide empirical antibiotic therapy. more...

We assessed methicillin-resistantStaphylococcus aureus(MRSA) infection and colonization in hospitalized prisoners. Of 434 admission surveillance cultures, 58 (13%) were positive for MRSA. The sensitivity of admission surveillance cultures of samples from the anterior nares was 72% and increased to 84% when the calculation included cultures of wound samples. Hospitalized prisoners are at high risk for MRSA infection and colonization, and surveillance should include cultures of nares and wound samples. more...

Emergency department (ED) screening for intimate partner violence (IPV) faces logistic difficulties and has uncertain efficacy. We surveyed 146 ED visitors and 108 ED care providers to compare their support for ED IPV screening in three hypothetical scenarios of varying IPV risk. Visitor support for screening was 5 times higher for the high-risk (86%) than for the low-risk (17%) scenario. Providers showed significantly more support for the need for ED IPV screening than visitors. Controlling for confounding by gender, race, experience with IPV, hospital, and marital status did not affect comparisons between groups. These responses indicate greater support for IPV screening in the ED for high-risk than for low-risk cases, particularly among visitors. more...

Background No simple, cost-effective methods exist to identify patients at high risk for methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci colonization outside intensive care settings. Without such methods, colonized patients are entering hospitals undetected and transmitting these bacteria to other patients. We aimed to develop a highly sensitive, simple-to-administer prediction rule to identify subpopulations of patients at high risk for colonization on hospital admission. Methods We conducted a prospective cohort study of adult patients admitted to the general medical and surgical wards of a tertiary-care facility. Data were collected using electronic medical records and an investigator-administered questionnaire. Cultures of anterior nares and the perirectal area were also collected within 48 hours of admission. Results Among 699 patients who enrolled in this study, 697 underwent nasal cultures; 555, perirectal cultures; and 553, both. Patient self-report of a hospital admission in the previous year was the most sensitive variable in identifying patients colonized with methicillin-resistant Staphylococcus aureus or with either organism (sensitivity, 76% and 90%, respectively). A prediction rule requiring patients to self-report having received antibiotics and a hospital admission in the previous year would have identified 100% of patients colonized with vancomycin-resistant enterococci. In the high-risk groups defined by the prediction rule, the prevalence of colonization by methicillin-resistant Staphylococcus aureus , vancomycin-resistant enterococci, or either organism were 8.1%, 10.2%, and 15.0%, respectively. Conclusion Patients with a self-reported previous admission within 1 year may represent a high-risk group for colonization by methicillin-resistant Staphylococcus aureus or vancomycin-resistant enterococci at hospital admission and should be considered for targeted active surveillance culturing. more...

High prevalence of co-colonization increases risk for colonization or infection by vancomycin-resistant Staphylococcus aureus., We assessed the prevalence, risk factors, and clinical outcomes of patients co-colonized with vancomycin-resistant enterococci (VRE) and methicillin-resistant Staphylococcus aureus (MRSA) upon admission to the medical and surgical intensive care units (ICUs) of a tertiary-care facility between January 1, 2002, and December 31, 2003. Co-colonization was defined as a VRE-positive perirectal surveillance culture with an MRSA-positive anterior nares surveillance culture collected concurrently. Among 2,440 patients, 65 (2.7%) were co-colonized. Independent risk factors included age (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01–1.05), admission to the medical ICU (OR 4.38, 95% CI 2.46–7.81), male sex (OR 1.93, 95% CI 1.14–3.30), and receiving antimicrobial drugs on a previous admission within 1 year (OR 3.06, 95% CI 1.85–5.07). None of the co-colonized patients would have been identified with clinical cultures alone. We report a high prevalence of VRE/MRSA co-colonization upon admission to ICUs at a tertiary-care hospital. more...

Objectives Comorbidities are often included in risk-factor models for nosocomial antibiotic-resistant bacterial infections, and aggregate comorbidity measures are valuable because they allow one variable to represent many. This study aimed to develop new aggregate comorbidity measures based upon the Chronic Disease Score (CDS) for assessing the comorbidity-attributable risk of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) nosocomial infections. Study Design and Setting For each outcome, two retrospective cohort studies of hospitalized patients were conducted. Outcomes were a first MRSA or VRE positive clinical culture obtained 48 hours or more postadmission. Each cohort was divided into development (July 1998–2001) and validation (August 2001–2003) samples. New comorbidity measures were created for MRSA (CDS-MRSA), VRE (CDS-VRE), or any nosocomial infection outcome (CDS-ID) using logistic regression and subsequently validated. Model discrimination was measured using the c-statistic. Results Discrimination of the CDS-MRSA (c = 0.60), CDS-VRE (c = 0.65), and CDS-ID (MRSA: c = 0.57; VRE: c = 0.64) was greater than that of the original CDS (MRSA: c = 0.52; VRE: c = 0.57). Conclusion The CDS-MRSA, CDS-VRE, and CDS-ID are new infectious disease specific comorbidity risk-adjustment measures that will be useful for the quality of future epidemiologic studies of MRSA, VRE, and other infectious diseases. more...

Background In 2003, the Society of Healthcare Epidemiology of America (SHEA) recommended surveillance cultures upon hospital admission for patients at high risk for carriage of vancomycin-resistant enterococci (VRE) and methicillin-resistant Staphylococcus aureus (MRSA). The aim of this study was to assess the validity of factors from past medical history in defining patients at high risk for subsequent positive cultures with VRE or MRSA upon hospital admission. Methods Subjects were adult inpatients admitted to nonintensive care wards of the index hospital during 2001-2002. Cases had MRSA or VRE positive clinical cultures within 48 hours of hospital admission. Patients with previous history of MRSA or VRE were excluded. Results Nineteen thousand three hundred ninety-nine patients were included, with 273 cases of VRE or MRSA. Previous admission within 1 year of current admission had a sensitivity of 56.8% and a specificity of 88.4% for predicting a case of MRSA or VRE. Individually, the sensitivity and specificity for admission within the past year were 50.5% and 88.4%, respectively, for MRSA and 76.9% and 88.4%, respectively, for VRE. Conclusions Patients with a previous hospital admission represent a high-risk population for positive culture for VRE and MRSA and may be a group of which active surveillance is indicated. more...

Weight gain during pregnancy (termed maternal weight gain) is an important predictor of maternal and infant health. This analysis was conducted to examine if cigarette smoking during pregnancy was associated with low maternal weight gain, as defined by the Institute of Medicine's (IOM) recommendations, independent of caloric intake.The participants were 265 Medicaid-eligible, pregnant women. Data were self-reported. Low maternal weight gain was defined as gaining less than the IOM recommendation for a given prepregnancy body mass index (BMI). Logistic regression was used to determine if smokers had greater odds of low maternal weight gain independent of caloric intake.Approximately 21% of the participants were self-reported smokers. No difference was observed in mean maternal weight gain between smokers and nonsmokers (14.4 kg vs. 13.9 kg, respectively, p = 0.80). However, a greater proportion of smokers were categorized as having low maternal weight gain compared with nonsmokers (35.7% vs. 31.1%). Unadjusted regression analysis showed that the odds of low maternal weight gain were 1.34 times greater for smokers than nonsmokers (odds ratio [OR] = 1.34, 95% confidence interval [CI] 0.73, 2.67). The OR did not materially change after adjustment for daily caloric intake, age, and length of gestation. In addition, the data suggest that the more cigarettes smoked, the higher the odds of having low maternal weight gain.The results suggest that cigarette smoking is associated with low maternal weight gain, as defined by the IOM recommendations, independent of caloric intake. more...

Background Contact Isolation is a common hospital infection prevention method that may improve infectious outcomes but may also hinder healthcare delivery. Methods To evaluate the impact of Contact Isolation on compliance with individual and composite process of care quality measures, we formed four retrospective diagnosis-based cohorts from a 662-bed tertiary-care medical center. Each cohort contained patients evaluated for one of four Centers for Medicare and Medicaid Services (CMS) Hospital Compare process measures including Acute Myocardial Infarction (AMI), Congestive Heart Failure (CHF), Pneumonia (PNA) and Surgical Care Improvement Project (SCIP) from January 1, 2007 through May 30, 2009. Results The 6716-admission cohort included 1259 with AMI, 834 with CHF, 1377 with PNA and 3246 in SCIP. Contact Isolation was associated with not meeting 4 of 23 individual hospital measures (4 of 10 measures were not met for care provided while patients are typically isolated). Contact Isolation was independently associated with lower compliance with the composite pneumonia process-of-care measure (OR 0.3, 95% CI 0.1–0.7). AMI, CHF and SCIP composite measures were not impacted by Contact Isolation. Conclusions Contact Isolation was associated with lower adherence to some pneumonia quality of care process measures of care on inpatient wards but did not impact CHF, AMI or SCIP measures. more...

Fibrotic scars are frequently found in proximity to lung cancer at the time of cancer diagnosis. However, the nature of the relationship between pulmonary scarring and lung cancer remains uncertain. Our objective was to test whether localized pulmonary scarring is associated with increased lung cancer risk.Cohort analysis of data from the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial. We included 66 863 cancer-free trial participants aged 55 to 74 years, who received a baseline chest radiographic examination and were followed up subsequently for up to 12 years. We used proportional hazards models to estimate hazard ratios (HRs) for lung cancer associated with scarring, adjusting for age, sex, race, and cigarette smoking, and in relation to laterality of scarring. The main outcome measure was incident lung cancer.Scarring was present on the baseline chest radiograph for 5041 subjects (7.5%). Scarring was associated with elevated lung cancer risk (809 lung cancer cases [HR, 1.5; 95% confidence interval {CI}, 1.2-1.8]). This association was specific for cancer in the lung ipsilateral to the scar (HR, 1.8; 95% CI, 1.4-2.4) and absent for contralateral cancer (HR, 0.9; 95% CI, 0.7-1.2). Ipsilateral lung cancer risk was elevated throughout the follow-up period (interval-specific HRs, 1.6, 2.0, 2.1, and 1.7 during 0.01-2.00, 2.01-4.00, 4.01-6.00, and 6.01-12.00 years after baseline chest radiography, respectively).The relationship between pulmonary scarring and lung cancer was specific to the same lung and extended over time. These findings are consistent with the hypothesis that localized inflammatory processes associated with scarring promote the subsequent development of lung cancer. more...

Background HIV patients are at increased risk of development of infections and infection-associated poor health outcomes. We aimed to 1) assess the prevalence of USA300 community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) among HIV-infected patients with S. aureus bloodstream infections and. 2) determine risk factors for infective endocarditis and in-hospital mortality among patients in this population. Methods All adult HIV-infected patients with documented S. aureus bacteremia admitted to the University of Maryland Medical Center between January 1, 2003 and December 31, 2005 were included. CA-MRSA was defined as a USA300 MRSA isolate with the MBQBLO spa-type motif and positive for both the arginine catabolic mobile element and Panton-Valentin Leukocidin. Risk factors for S. aureus-associated infective endocarditis and mortality were determined using logistic regression to calculate odds ratios (OR) and 95% confidence intervals (CI). Potential risk factors included demographic variables, comorbid illnesses, and intravenous drug use. Results Among 131 episodes of S. aureus bacteremia, 85 (66%) were MRSA of which 47 (54%) were CA-MRSA. Sixty-three patients (48%) developed endocarditis and 10 patients (8%) died in the hospital on the index admission Patients with CA-MRSA were significantly more likely to develop endocarditis (OR = 2.73, 95% CI = 1.30, 5.71). No other variables including comorbid conditions, current receipt of antiretroviral therapy, pre-culture severity of illness, or CD4 count were significantly associated with endocarditis and none were associated with in-hospital mortality. Conclusions CA-MRSA was significantly associated with an increased incidence of endocarditis in this cohort of HIV patients with MRSA bacteremia. In populations such as these, in which the prevalence of intravenous drug use and probability of endocarditis are both high, efforts must be made for early detection, which may improve treatment outcomes. more...

Background The high prevalence of methicillin-resistant S. aureus (MRSA) has led clinicians to select antibiotics that have coverage against MRSA, usually vancomycin, for empiric therapy for suspected staphylococcal infections. Clinicians often continue vancomycin started empirically even when methicillin-susceptible S. aureus (MSSA) strains are identified by culture. However, vancomycin has been associated with poor outcomes such as nephrotoxicity, persistent bacteremia and treatment failure. The objective of this study was to compare the effectiveness of vancomycin versus the beta-lactam antibiotics nafcillin and cefazolin among patients with MSSA bacteremia. The outcome of interest for this study was 30-day in-hospital mortality. Methods This retrospective cohort study included all adult in-patients admitted to a tertiary-care facility between January 1, 2003 and June 30, 2007 who had a positive blood culture for MSSA and received nafcillin, cefazolin or vancomycin. Cox proportional hazard models were used to assess independent mortality hazards comparing nafcillin or cefazolin versus vancomycin. Similar methods were used to estimate the survival benefits of switching from vancomycin to nafcillin or cefazolin versus leaving patients on vancomycin. Each model included statistical adjustment using propensity scores which contained variables associated with an increased propensity to receive vancomycin. Results 267 patients were included; 14% (38/267) received nafcillin or cefazolin, 51% (135/267) received both vancomycin and either nafcillin or cefazolin, and 35% (94/267) received vancomycin. Thirty (11%) died within 30 days. Those receiving nafcillin or cefazolin had 79% lower mortality hazards compared with those who received vancomycin alone (adjusted hazard ratio (HR): 0.21; 95% confidence interval (CI): 0.09, 0.47). Among the 122 patients who initially received vancomycin empirically, those who were switched to nafcillin or cefazolin (66/122) had 69% lower mortality hazards (adjusted HR: 0.31; 95% CI: 0.10, 0.95) compared to those who remained on vancomycin. Conclusions Receipt of nafcillin or cefazolin was protective against mortality compared to vancomycin even when therapy was altered after culture results identified MSSA. Convenience of vancomycin dosing may not outweigh the potential benefits of nafcillin or cefazolin in the treatment of MSSA bacteremia. more...