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Background: Antibiotics are overprescribed for acute respiratory tract infections (ARIs). Guidelines provide criteria to determine which patients should receive antibiotics. We assessed congruence between documentation of ARI diagnostic and treatment practices with guideline recommendations, treatment appropriateness, and outcomes., Methods: A multicenter quality improvement evaluation was conducted in 28 Veterans Affairs facilities. We included visits for pharyngitis, rhinosinusitis, bronchitis, and upper respiratory tract infections (URI-NOS) that occurred during the 2015-2016 winter season. A manual record review identified complicated cases, which were excluded. Data were extracted for visits meeting criteria, followed by analysis of practice patterns, guideline congruence, and outcomes., Results: Of 5,740 visits, 4,305 met our inclusion criteria: pharyngitis (n = 558), rhinosinusitis (n = 715), bronchitis (n = 1,155), URI-NOS (n = 1,475), or mixed diagnoses (>1 ARI diagnosis) (n = 402). Antibiotics were prescribed in 68% of visits: pharyngitis (69%), rhinosinusitis (89%), bronchitis (86%), URI-NOS (37%), and mixed diagnosis (86%). Streptococcal diagnostic testing was performed in 33% of pharyngitis visits; group A Streptococcus was identified in 3% of visits. Streptococcal tests were ordered less frequently for patients who received antibiotics (28%) than those who did not receive antibiotics 44%; P < .01). Although 68% of visits for rhinosinusitis had documentation of symptoms, only 32% met diagnostic criteria for antibiotics. Overall, 39% of patients with uncomplicated ARIs received appropriate antibiotic management. The proportion of 30-day return visits for ARI care was similar for appropriate (11%) or inappropriate (10%) antibiotic management (P = .22)., Conclusions: Antibiotics were prescribed in most uncomplicated ARI visits, indicating substantial overuse. Practice was frequently discordant with guideline diagnostic and treatment recommendations.

Introduction: By 2007, all Department of Veterans Affairs medical centers (VAMCs) had initiated a multifaceted methicillin-resistant Staphylococcus aureus (MRSA) prevention program. MRSA and methicillin-susceptible S. aureus (MSSA) infection rates among VAMC inpatients from 2005 to 2017 were assessed., Methods: Clinical microbiology data from any patient admitted to an acute-care VAMC in the United States from 2005 through 2017 and trends in hospital-acquired MRSA colonization were examined., Results: S. aureus infections decreased by 43% overall during the study period (p<0.001), driven primarily by decreases in MRSA, which decreased by 55% (p<0.001), whereas MSSA decreased by 12% (p = 0.003). Hospital-onset MRSA and MSSA infections decreased by 66% (p<0.001) and 19% (p = 0.02), respectively. Community-onset MRSA infections decreased by 41% (p<0.001), whereas MSSA infections showed no significant decline. Acquisition of MRSA colonization decreased 78% during 2008-2017 (17% annually, p<0.001). MRSA infection rates declined more sharply among patients who had negative admission surveillance MRSA screening tests (annual 9.7% decline) compared with those among patients with positive admission MRSA screening tests (4.2%) (p<0.05)., Conclusions and Implications for Public Health Practice: Significant reductions in S. aureus infection following the VAMC intervention were led primarily by decreases in MRSA. Moreover, MRSA infection declines were much larger among patients not carrying MRSA at the time of admission than among those who were. Taken together, these results suggest that decreased MRSA transmission played a substantial role in reducing overall S. aureus infections at VAMCs. Recent calls to withdraw infection control interventions designed to prevent MRSA transmission might be premature and inadvisable, at least until more is known about effective control of bacterial pathogen transmission in health care settings. Effective S. aureus prevention strategies require a multifaceted approach that includes adherence to current CDC recommendations for preventing not only device- and procedure-associated infections, but also transmission of health care-prevalent strains.

Background: The Department of Veterans Affairs implemented an active surveillance program for methicillin-resistant Staphylococcus aureus (MRSA) in 2007 in which acute care inpatients are tested for MRSA carriage on admission, unit-to-unit transfer, and discharge. Using these data, we followed patients longitudinally to estimate the difference in infection rates for those who were not colonized, those who were colonized on admission (importers), and those who acquired MRSA during their stay. We examined MRSA infections that occurred prior to discharge and at 30, 90, 180, and 365 days after discharge., Methods: We constructed a dataset of 985626 first admissions from January 2008 through December 2015 who had surveillance tests performed for MRSA carriage. We performed multivariable Cox proportional hazards and logistic regression models to examine the relationship between MRSA colonization status and infection., Results: The MRSA infection rate across the predischarge and 180-day postdischarge time period was 5.5% in importers and 7.0% in acquirers without a direct admission to the intensive care unit (ICU) and 11.4% in importers and 11.7% in acquirers who were admitted directly to the ICU. The predischarge hazard ratio for MRSA infection was 29.6 (95% confidence interval [CI], 26.5-32.9) for importers and 28.8 (95% CI, 23.5-35.3) for acquirers compared to those not colonized. Fully 63.9% of all MRSA pre- and postdischarge infections among importers and 61.2% among acquirers occurred within 180 days after discharge., Conclusions: MRSA colonization significantly increases the risk of subsequent MRSA infection. In addition, a substantial proportion of MRSA infections occur after discharge from the hospital.

Objective: To measure how much of the postdischarge cost and utilization attributable to methicillin-resistant Staphylococcus aureus (MRSA) health care-associated infections (HAIs) occur within the US Department of Veterans Affairs (VA) system and how much occurs outside., Data Sources/study Setting: Health care encounters from 3 different settings and payment models: (1) within the VA; (2) outside the VA but paid for by the VA (purchased care); and (3) outside the VA and paid for by Medicare., Study Design: Historical cohort study using data from admissions to VA hospitals between 2007 and 2012., Methods: We assessed the impact of a positive MRSA test result on costs and utilization during the 365 days following discharge using inverse probability of treatment weights to balance covariates., Principal Findings: Among a cohort of 152,687 hospitalized Veterans, a positive MRSA test result was associated with an overall increase of 6.6 (95 percent CI: 5.7-7.5) inpatient days and $9,237 (95 percent CI: $8,211-$10,262) during the postdischarge period. VA inpatient admissions, Medicare reimbursements, and purchased care payments accounted for 60.6 percent, 22.5 percent, and 16.9 percent of these inpatient costs., Conclusions: While most of the excess postdischarge health care costs associated with MRSA HAIs occurred in the VA, non-VA costs make up an important subset of the overall burden., (© Health Research and Educational Trust.)

Few studies have estimated the excess inpatient costs due to nosocomial cultures of Gram-negative bacteria (GNB), and those that do are often subject to time-dependent bias. Our objective was to generate estimates of the attributable costs of the underlying infections associated with nosocomial cultures by using a unique inpatient cost data set from the U.S. Department of Veterans Affairs that allowed us to reduce time-dependent bias. Our study included data from inpatient admissions between 1 October 2007 and 30 November 2010. Nosocomial GNB-positive cultures were defined as clinical cultures positive for Acinetobacter , Pseudomonas , or Enterobacteriaceae between 48 h after admission and discharge. Positive cultures were further classified by site and level of resistance. We conducted analyses using both a conventional approach and an approach aimed at reducing the impact of time-dependent bias. In both instances, we used multivariable generalized linear models to compare the inpatient costs and length of stay for patients with and without a nosocomial GNB culture. Of the 404,652 patients included in the conventional analysis, 12,356 had a nosocomial GNB-positive culture. The excess costs of nosocomial GNB-positive cultures were significant, regardless of specific pathogen, site, or resistance level. Estimates generated using the conventional analysis approach were 32.0% to 131.2% greater than those generated using the approach to reduce time-dependent bias. These results are important because they underscore the large financial burden attributable to these infections and provide a baseline that can be used to assess the impact of improvements in infection control., (Copyright © 2018 American Society for Microbiology.)

Objectives: Inappropriate antibiotic use poses a serious threat to patient safety. Antimicrobial stewardship programmes (ASPs) may optimize antimicrobial use and improve patient outcomes, but their implementation remains an organizational challenge. Using the Promoting Action on Research Implementation in Health Services (PARiHS) framework, this study aimed to identify organizational factors that may facilitate ASP design, development and implementation., Methods: Among 130 Veterans Affairs facilities that offered acute care, we classified organizational variables supporting antimicrobial stewardship activities into three PARiHS domains: evidence to encompass sources of knowledge; contexts to translate evidence into practice; and facilitation to enhance the implementation process. We conducted a series of exploratory factor analyses to identify conceptually linked factor scales. Cronbach's alphas were calculated. Variables with large uniqueness values were left as single factors., Results: We identified 32 factors, including six constructs derived from factor analyses under the three PARiHS domains. In the evidence domain, four factors described guidelines and clinical pathways. The context domain was broken into three main categories: (i) receptive context (15 factors describing resources, affiliations/networks, formalized policies/practices, decision-making, receptiveness to change); (ii) team functioning (1 factor); and (iii) evaluation/feedback (5 factors). Within facilitation, two factors described facilitator roles and tasks and five captured skills and training., Conclusions: We mapped survey data onto PARiHS domains to identify factors that may be adapted to facilitate ASP uptake. Our model encompasses mostly mutable factors whose relationships with performance outcomes may be explored to optimize antimicrobial use. Our framework also provides an analytical model for determining whether leveraging existing organizational processes can potentially optimize ASP performance.

We consider extensions to previous models for patient level nosocomial infection in several ways, provide a specification of the likelihoods for these new models, specify new update steps required for stochastic integration, and provide programs that implement these methods to obtain parameter estimates and model choice statistics. Previous susceptible-infected models are extended to allow for a latent period between initial exposure to the pathogen and the patient becoming themselves infectious, and the possibility of decolonization. We allow for multiple facilities, such as acute care hospitals or long-term care facilities and nursing homes, and for multiple units or wards within a facility. Patient transfers between units and facilities are tracked and accounted for in the models so that direct importation of a colonized individual from one facility or unit to another might be inferred. We allow for constant transmission rates, rates that depend on the number of colonized individuals in a unit or facility, or rates that depend on the proportion of colonized individuals. Statistical analysis is done in a Bayesian framework using Markov chain Monte Carlo methods to obtain a sample of parameter values from their joint posterior distribution. Cross validation, deviance information criterion and widely applicable information criterion approaches to model choice fit very naturally into this framework and we have implemented all three. We illustrate our methods by considering model selection issues and parameter estimation for data on methicilin-resistant Staphylococcus aureus surveillance tests over 1 year at a Veterans Administration hospital comprising seven wards.

Background: Antimicrobial stewardship to combat the spread of antibiotic-resistant bacteria has become a national priority. This project focuses on reducing inappropriate use of antimicrobials for asymptomatic bacteriuria (ASB), a very common condition that leads to antimicrobial overuse in acute and long-term care. We previously conducted a successful intervention, entitled "Kicking Catheter Associated Urinary Tract Infection (CAUTI): the No Knee-Jerk Antibiotics Campaign," to decrease guideline-discordant ordering of urine cultures and antibiotics for ASB. The current objective is to facilitate implementation of a scalable version of the Kicking CAUTI campaign across four geographically diverse Veterans Health Administration facilities while assessing what aspects of an antimicrobial stewardship intervention are essential to success and sustainability., Methods: This project uses an interrupted time series design with four control sites. The two main intervention tools are (1) an evidence-based algorithm that distills the guidelines into a streamlined clinical pathway and (2) case-based audit and feedback to train clinicians to use the algorithm. Our conceptual framework for the development and implementation of this intervention draws on May's General Theory of Implementation. The intervention is directed at providers in acute and long-term care, and the goal is to reduce inappropriate screening for and treatment of ASB in all patients and residents, not just those with urinary catheters. The start-up for each facility consists of centrally-led phone calls with local site champions and baseline surveys. Case-based audit and feedback will begin at a given site after the start-up period and continue for 12 months, followed by a sustainability assessment. In addition to the clinical outcomes, we will explore the relationship between the dose of the intervention and clinical outcomes., Discussion: This project moves from a proof-of-concept effectiveness study to implementation involving significantly more sites, and uses the General Theory of Implementation to embed the intervention into normal processes of care with usual care providers. Aspects of implementation that will be explored include dissemination, internal and external facilitation, and organizational partnerships. "Less is More" is the natural next step from our prior successful Kicking CAUTI intervention, and has the potential to improve patient care while advancing the science of implementation.

Background: Drivers of differences in Clostridium difficile incidence across acute and long-term care facilities are poorly understood. We sought to obtain a comprehensive picture of C. difficile incidence and risk factors in acute and long-term care., Methods: We conducted a case-cohort study of persons spending at least 3 days in one of 131 acute care or 120 long-term care facilities managed by the United States Veterans Health Administration between 2006 and 2012. Patient (n = 8) and facility factors (n = 5) were included in analyses. The outcome was the incidence of facility-onset laboratory-identified C. difficile infection (CDI), defined as a person with a positive C. difficile test without a positive test in the prior 8 weeks., Results: CDI incidence in acute care was 5 times that observed in long-term care (median, 15.6 vs 3.2 per 10000 person-days). History of antibiotic use was greater in acute care compared to long-term care (median, 739 vs 513 per 1000 person-days) and explained 72% of the variation in C. difficile rates. Importation of C. difficile cases (acute care: patients with recent long-term care attributable infection; long-term care: residents with recent acute care attributable infection) was 3 times higher in long-term care as compared to acute care (median, 52.3 vs 16.2 per 10000 person-days)., Conclusions: Facility-level antibiotic use was the main factor driving differences in CDI incidence between acute and long-term care. Importation of acute care C. difficile cases was a greater concern for long-term care as compared to importation of long-term care cases for acute care., (© The Author 2017. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Background: To treat patients with methicillin-susceptible Staphylococcus aureus (MSSA) infections, β-lactams are recommended for definitive therapy; however, the comparative effectiveness of individual β-lactams is unknown. This study compared definitive therapy with cefazolin vs nafcillin or oxacillin among patients with MSSA infections complicated by bacteremia., Methods: This retrospective study included patients admitted to 119 Veterans Affairs hospitals from 2003 to 2010. Patients were included if they had a blood culture positive for MSSA and received definitive therapy with cefazolin, nafcillin, or oxacillin. Cox proportional hazards regression and ordinal logistic regression were used to identify associations between antibiotic therapy and mortality or recurrence. A recurrent infection was defined as a MSSA blood culture between 45 and 365 days after the first MSSA blood culture., Results: Of 3167 patients, 1163 (37%) patients received definitive therapy with cefazolin. Patients who received cefazolin had a 37% reduction in 30-day mortality (hazard ratio [HR], 0.63; 95% confidence interval [CI], .51-.78) and a 23% reduction in 90-day mortality (HR, 0.77; 95% CI, .66-.90) compared with patients receiving nafcillin or oxacillin, after controlling for other factors. The odds of recurrence (odds ratio, 1.13; 95% CI, .94-1.36) were similar among patients who received cefazolin compared with patients who received nafcillin or oxacillin, after controlling for other factors., Conclusions: In this large, multicenter study, patients who received cefazolin had a lower risk of mortality and similar odds of recurrent infections compared with nafcillin or oxacillin for MSSA infections complicated by bacteremia. Physicians might consider definitive therapy with cefazolin for these infections., (© The Author 2017. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Background: Understanding complexity in healthcare has the potential to reduce decision and treatment uncertainty. Therefore, identifying both patient and task complexity may offer better task allocation and design recommendation for next-generation health information technology system design., Objective: To identify specific complexity-contributing factors in the infectious disease domain and the relationship with the complexity perceived by clinicians., Method: We observed and audio recorded clinical rounds of three infectious disease teams. Thirty cases were observed for a period of four consecutive days. Transcripts were coded based on clinical complexity-contributing factors from the clinical complexity model. Ratings of complexity on day 1 for each case were collected. We then used statistical methods to identify complexity-contributing factors in relationship to perceived complexity of clinicians., Results: A factor analysis (principal component extraction with varimax rotation) of specific items revealed three factors (eigenvalues>2.0) explaining 47% of total variance, namely task interaction and goals (10 items, 26%, Cronbach's Alpha=0.87), urgency and acuity (6 items, 11%, Cronbach's Alpha=0.67), and psychosocial behavior (4 items, 10%, Cronbach's alpha=0.55). A linear regression analysis showed no statistically significant association between complexity perceived by the physicians and objective complexity, which was measured from coded transcripts by three clinicians (Multiple R-squared=0.13, p=0.61). There were no physician effects on the rating of perceived complexity., Conclusion: Task complexity contributes significantly to overall complexity in the infectious diseases domain. The different complexity-contributing factors found in this study can guide health information technology system designers and researchers for intuitive design. Thus, decision support tools can help reduce the specific complexity-contributing factors. Future studies aimed at understanding clinical domain-specific complexity-contributing factors can ultimately improve task allocation and design for intuitive clinical reasoning., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objectives: To understand clinicians' impressions of and decision-making processes regarding an informatics-supported antibiotic timeout program to re-evaluate the appropriateness of continuing vancomycin and piperacillin/tazobactam., Methods: We implemented a multi-pronged informatics intervention, based on Dual Process Theory, to prompt discontinuation of unwarranted vancomycin and piperacillin/tazobactam on or after day three in a large Veterans Affairs Medical Center. Two workflow changes were introduced to facilitate cognitive deliberation about continuing antibiotics at day three: (1) teams completed an electronic template note, and (2) a paper summary of clinical and antibiotic-related information was provided to clinical teams. Shortly after starting the intervention, six focus groups were conducted with users or potential users. Interviews were recorded and transcribed. Iterative thematic analysis identified recurrent themes from feedback., Results: Themes that emerged are represented by the following quotations: (1) captures and controls attention ("it reminds us to think about it"), (2) enhances informed and deliberative reasoning ("it makes you think twice"), (3) redirects decision direction ("…because [there was no indication] I just [discontinued] it without even trying"), (4) fosters autonomy and improves team empowerment ("the template… forces the team to really discuss it"), and (5) limits use of emotion-based heuristics ("my clinical concern is high enough I think they need more aggressive therapy…")., Conclusions: Requiring template completion to continue antibiotics nudged clinicians to re-assess the appropriateness of specified antibiotics. Antibiotic timeouts can encourage deliberation on overprescribed antibiotics without substantially curtailing autonomy. An effective nudge should take into account clinician's time, workflow, and thought processes., (Published by Elsevier Inc.)

De-escalation, an antimicrobial stewardship concept, involves narrowing broad-spectrum empiric antimicrobial therapy based on clinical data. Current health outcomes evidence is lacking to support de-escalation. Studying Veterans Healthcare Administration pneumonia patients, de-escalation was associated with improved length of stay without affecting 30-day readmission or 30-day Clostridium difficile infection rates.

Objective: Big data or population-based information has the potential to reduce uncertainty in medicine by informing clinicians about individual patient care. The objectives of this study were: 1) to explore the feasibility of extracting and displaying population-based information from an actual clinical population's database records, 2) to explore specific design features for improving population display, 3) to explore perceptions of population information displays, and 4) to explore the impact of population information display on cognitive outcomes., Methods: We used the Veteran's Affairs (VA) database to identify similar complex patients based on a similar complex patient case. Study outcomes measures were 1) preferences for population information display 2) time looking at the population display, 3) time to read the chart, and 4) appropriateness of plans with pre- and post-presentation of population data. Finally, we redesigned the population information display based on our findings from this study., Results: The qualitative data analysis for preferences of population information display resulted in four themes: 1) trusting the big/population data can be an issue, 2) embedded analytics is necessary to explore patient similarities, 3) need for tools to control the view (overview, zoom and filter), and 4) different presentations of the population display can be beneficial to improve the display. We found that appropriateness of plans was at 60% for both groups (t9=-1.9; p=0.08), and overall time looking at the population information display was 2.3 minutes versus 3.6 minutes with experts processing information faster than non-experts (t8= -2.3, p=0.04)., Conclusion: A population database has great potential for reducing complexity and uncertainty in medicine to improve clinical care. The preferences identified for the population information display will guide future health information technology system designers for better and more intuitive display.

Background: Although clinical factors affecting a person's susceptibility to Clostridium difficile infection are well-understood, little is known about what drives differences in incidence across long-term care settings., Objective: To obtain a comprehensive picture of individual and regional factors that affect C difficile incidence., Design: Multilevel longitudinal nested case-control study., Setting: Veterans Health Administration health care regions, from 2006 through 2012., Participants: Long-term care residents., Measurements: Individual-level risk factors included age, number of comorbid conditions, and antibiotic exposure. Regional risk factors included importation of cases of acute care C difficile infection per 10 000 resident-days and antibiotic use per 1000 resident-days. The outcome was defined as a positive result on a long-term care C difficile test without a positive result in the prior 8 weeks., Results: 6012 cases (incidence, 3.7 cases per 10 000 resident-days) were identified in 86 regions. Long-term care C difficile incidence (minimum, 0.6 case per 10 000 resident-days; maximum, 31.0 cases per 10 000 resident-days), antibiotic use (minimum, 61.0 days with therapy per 1000 resident-days; maximum, 370.2 days with therapy per 1000 resident-days), and importation (minimum, 2.9 cases per 10 000 resident-days; maximum, 341.3 cases per 10 000 resident-days) varied substantially across regions. Together, antibiotic use and importation accounted for 75% of the regional variation in C difficile incidence (R2 = 0.75). Multilevel analyses showed that regional factors affected risk together with individual-level exposures (relative risk of regional antibiotic use, 1.36 per doubling [95% CI, 1.15 to 1.60]; relative risk of importation, 1.23 per doubling [CI, 1.14 to 1.33])., Limitations: Case identification was based on laboratory criteria. Admission of residents with recent C difficile infection from non-Veterans Health Administration acute care sources was not considered., Conclusion: Only 25% of the variation in regional C difficile incidence in long-term care remained unexplained after importation from acute care facilities and antibiotic use were accounted for, which suggests that improved infection control and antimicrobial stewardship may help reduce the incidence of C difficile in long-term care settings., Primary Funding Source: U.S. Department of Veterans Affairs and Centers for Disease Control and Prevention.

BACKGROUND Antimicrobial stewardship programs (ASPs) are variably implemented. OBJECTIVE To characterize variations of antimicrobial stewardship structure and practices across all inpatient Veterans Affairs facilities in 2012 and correlate key characteristics with antimicrobial usage. DESIGN A web-based survey regarding stewardship activities was administered to each facility's designated contact. Bivariate associations between facility characteristics and inpatient antimicrobial use during 2012 were determined. SETTING Total of 130 Veterans Affairs facilities with inpatient services. RESULTS Of 130 responding facilities, 29 (22%) had a formal policy establishing an ASP, and 12 (9%) had an approved ASP business plan. Antimicrobial stewardship teams were present in 49 facilities (38%); 34 teams included a clinical pharmacist with formal infectious diseases (ID) training. Stewardship activities varied across facilities, including development of yearly antibiograms (122 [94%]), formulary restrictions (120 [92%]), stop orders for antimicrobial duration (98 [75%]), and written clinical pathways for specific conditions (96 [74%]). Decreased antimicrobial usage was associated with having at least 1 full-time ID physician (P=.03), an ID fellowship program (P=.003), and a clinical pharmacist with formal ID training (P=.006) as well as frequency of systematic patient-level reviews of antimicrobial use (P=.01) and having a policy to address antimicrobial use in the context of Clostridium difficile infection (P=.01). Stop orders for antimicrobial duration were associated with increased use (P=.03). CONCLUSIONS ASP-related activities varied considerably. Decreased antibiotic use appeared related to ID presence and certain select practices. Further statistical assessments may help optimize antimicrobial practices. Infect Control Hosp Epidemiol 2016;37:647-654.

Introduction: In an effort to reduce methicillin-resistant Staphylococcus aureus (MRSA) transmission through universal screening and isolation, the Department of Veterans Affairs (VA) launched the National MRSA Prevention Initiative in October 2007. The objective of this analysis was to quantify the budget impact and cost effectiveness of this initiative., Methods: An economic model was developed using published data on MRSA hospital-acquired infection (HAI) rates in the VA from October 2007 to September 2010; estimates of the costs of MRSA HAIs in the VA; and estimates of the intervention costs, including salaries of staff members hired to support the initiative at each VA facility. To estimate the rate of MRSA HAIs that would have occurred if the initiative had not been implemented, two different assumptions were made: no change and a downward temporal trend. Effectiveness was measured in life-years gained., Results: The initiative resulted in an estimated 1,466-2,176 fewer MRSA HAIs. The initiative itself was estimated to cost $207 million during this 3-year period, while the cost savings from prevented MRSA HAIs ranged from $27 million to $75 million. The incremental cost-effectiveness ratios ranged from $28,048 to $56,944/life-years. The overall impact on the VA's budget was $131-$179 million., Conclusions: Wide-scale implementation of a national MRSA surveillance and prevention strategy in VA inpatient settings may have prevented a substantial number of MRSA HAIs. Although the savings associated with prevented infections helped offset some but not all of the cost of the initiative, this model indicated that the initiative would be considered cost effective., (Copyright © 2016 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Background: A number of strategies exist to reduce Clostridium difficile (C. difficile) transmission. We conducted an economic evaluation of "bundling" these strategies together., Methods: We constructed an agent-based computer simulation of nosocomial C. difficile transmission and infection in a hospital setting. This model included the following components: interactions between patients and health care workers; room contamination via C. difficile shedding; C. difficile hand carriage and removal via hand hygiene; patient acquisition of C. difficile via contact with contaminated rooms or health care workers; and patient antimicrobial use. Six interventions were introduced alone and "bundled" together: (a) aggressive C. difficile testing; (b) empiric isolation and treatment of symptomatic patients; (c) improved adherence to hand hygiene and (d) contact precautions; (e) improved use of soap and water for hand hygiene; and (f) improved environmental cleaning. Our analysis compared these interventions using values representing 3 different scenarios: (1) base-case (BASE) values that reflect typical hospital practice, (2) intervention (INT) values that represent implementation of hospital-wide efforts to reduce C. diff transmission, and (3) optimal (OPT) values representing the highest expected results from strong adherence to the interventions. Cost parameters for each intervention were obtained from published literature. We performed our analyses assuming low, normal, and high C. difficile importation prevalence and transmissibility of C. difficile., Results: INT levels of the "bundled" intervention were cost-effective at a willingness-to-pay threshold of $100,000/quality-adjusted life-year in all importation prevalence and transmissibility scenarios. OPT levels of intervention were cost-effective for normal and high importation prevalence and transmissibility scenarios. When analyzed separately, hand hygiene compliance, environmental decontamination, and empiric isolation and treatment were the interventions that had the greatest impact on both cost and effectiveness., Conclusions: A combination of available interventions to prevent CDI is likely to be cost-effective but the cost-effectiveness varies for different levels of intensity of the interventions depending on epidemiological conditions such as C. difficile importation prevalence and transmissibility.

Objectives: The objective of this study was to measure quantitatively antimicrobial de-escalation utilizing electronic medication administration data based on the spectrum of activity for antimicrobial therapy (i.e. spectrum score) to identify variables associated with de-escalation in a nationwide healthcare system., Methods: A retrospective cohort study of patients hospitalized for healthcare-associated pneumonia was conducted in Veterans Affairs Medical Centers (n = 119). Patients hospitalized for healthcare-associated pneumonia on acute-care wards between 5 and 14 days who received antimicrobials for ≥ 3 days during calendar years 2008-11 were evaluated. The spectrum score method was applied at the patient level to measure de-escalation on day 4 of hospitalization. De-escalation was expressed in aggregate and facility-level proportions. Logistic regression was used to assess variables associated with de-escalation. ORs with 95% CIs were reported., Results: Among 9319 patients, the de-escalation proportion was 28.3% (95% CI 27.4-29.2), which varied 6-fold across facilities [median (IQR) facility-level de-escalation proportion 29.1% (95% CI 21.7-35.6)]. Variables associated with de-escalation included initial broad-spectrum therapy (OR 1.5, 95% CI 1.4-1.5 for each 10% increase in spectrum), collection of respiratory tract cultures (OR 1.1, 95% CI 1.0-1.2) and care in higher complexity facilities (OR 1.3, 95% CI 1.1-1.6). Respiratory tract cultures were collected from 35.3% (95% CI 32.7-37.7) of patients., Conclusions: De-escalation of antimicrobial therapy was limited and varied substantially across facilities. De-escalation was associated with respiratory tract culture collection and treatment in a high complexity-level facility., (© The Author 2015. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.)

Complex clinical decision-making could be facilitated by using population health data to inform clinicians. In two previous studies, we interviewed 16 infectious disease experts to understand complex clinical reasoning. For this study, we focused on answers from the experts on how clinical reasoning can be supported by population-based Big-Data. We found cognitive strategies such as trajectory tracking, perspective taking, and metacognition has the potential to improve clinicians' cognition to deal with complex problems. These cognitive strategies could be supported by population health data, and all have important implications for the design of Big-Data based decision-support tools that could be embedded in electronic health records. Our findings provide directions for task allocation and design of decision-support applications for health care industry development of Big data based decision-support systems.

Background: Clinical experts' cognitive mechanisms for managing complexity have implications for the design of future innovative healthcare systems. The purpose of the study is to examine the constituents of decision complexity and explore the cognitive strategies clinicians use to control and adapt to their information environment., Methods: We used Cognitive Task Analysis (CTA) methods to interview 10 Infectious Disease (ID) experts at the University of Utah and Salt Lake City Veterans Administration Medical Center. Participants were asked to recall a complex, critical and vivid antibiotic-prescribing incident using the Critical Decision Method (CDM), a type of Cognitive Task Analysis (CTA). Using the four iterations of the Critical Decision Method, questions were posed to fully explore the incident, focusing in depth on the clinical components underlying the complexity. Probes were included to assess cognitive and decision strategies used by participants., Results: The following three themes emerged as the constituents of decision complexity experienced by the Infectious Diseases experts: 1) the overall clinical picture does not match the pattern, 2) a lack of comprehension of the situation and 3) dealing with social and emotional pressures such as fear and anxiety. All these factors contribute to decision complexity. These factors almost always occurred together, creating unexpected events and uncertainty in clinical reasoning. Five themes emerged in the analyses of how experts deal with the complexity. Expert clinicians frequently used 1) watchful waiting instead of over- prescribing antibiotics, engaged in 2) theory of mind to project and simulate other practitioners' perspectives, reduced very complex cases into simple 3) heuristics, employed 4) anticipatory thinking to plan and re-plan events and consulted with peers to share knowledge, solicit opinions and 5) seek help on patient cases., Conclusion: The cognitive strategies to deal with decision complexity found in this study have important implications for design future decision support systems for the management of complex patients.

Background: Standard estimates of the impact of Clostridium difficile infections (CDI) on inpatient lengths of stay (LOS) may overstate inpatient care costs attributable to CDI. In this study, we used multistate modeling (MSM) of CDI timing to reduce bias in estimates of excess LOS., Methods: A retrospective cohort study of all hospitalizations at any of 120 acute care facilities within the US Department of Veterans Affairs (VA) between 2005 and 2012 was conducted. We estimated the excess LOS attributable to CDI using an MSM to address time-dependent bias. Bootstrapping was used to generate 95% confidence intervals (CI). These estimates were compared to unadjusted differences in mean LOS for hospitalizations with and without CDI., Results: During the study period, there were 3.96 million hospitalizations and 43,540 CDIs. A comparison of unadjusted means suggested an excess LOS of 14.0 days (19.4 vs 5.4 days). In contrast, the MSM estimated an attributable LOS of only 2.27 days (95% CI, 2.14-2.40). The excess LOS for mild-to-moderate CDI was 0.75 days (95% CI, 0.59-0.89), and for severe CDI, it was 4.11 days (95% CI, 3.90-4.32). Substantial variation across the Veteran Integrated Services Networks (VISN) was observed., Conclusions: CDI significantly contributes to LOS, but the magnitude of its estimated impact is smaller when methods are used that account for the time-varying nature of infection. The greatest impact on LOS occurred among patients with severe CDI. Significant geographic variability was observed. MSM is a useful tool for obtaining more accurate estimates of the inpatient care costs of CDI.

Background: Previous estimates of the excess costs due to health care-associated infection (HAI) have scarcely addressed the issue of time-dependent bias., Objective: We examined time-dependent bias by estimating the health care costs attributable to an HAI due to methicillin-resistant Staphylococcus aureus (MRSA) using a unique dataset in the Department of Veterans Affairs (VA) that makes it possible to distinguish between costs that occurred before and after an HAI. In addition, we compare our results to those from 2 other estimation strategies., Methods: Using a historical cohort study design to estimate the excess predischarge costs attributable to MRSA HAIs, we conducted 3 analyses: (1) conventional, in which costs for the entire inpatient stay were compared between patients with and without MRSA HAIs; (2) post-HAI, which included only costs that occurred after an infection; and (3) matched, in which costs for the entire inpatient stay were compared between patients with an MRSA HAI and subset of patients without an MRSA HAI who were matched based on the time to infection., Results: In our post-HAI analysis, estimates of the increase in inpatient costs due to MRSA HAI were $12,559 (P<0.0001) and $24,015 (P<0.0001) for variable and total costs, respectively. The excess variable and total cost estimates were 33.7% and 31.5% higher, respectively, when using the conventional methods and 14.6% and 11.8% higher, respectively, when using matched methods., Conclusions: This is the first study to account for time-dependent bias in the estimation of incremental per-patient health care costs attributable to HAI using a unique dataset in the VA. We found that failure to account for this bias can lead to overestimation of these costs. Matching on the timing of infection can reduce this bias substantially.

Objective: Healthcare-associated methicillin-resistant Staphylococcus aureus (MRSA) infections are a major cause of morbidity, mortality, and cost among hospitalized patients. Little is known about their impact on post-discharge resource utilization. The purpose of this study was to estimate post-discharge healthcare costs and utilization attributable to positive MRSA cultures during a hospitalization., Methods: Our study cohort consisted of patients with an inpatient admission lasting longer than 48 hours within the US Department of Veterans Affairs (VA) system between October 1, 2007, and November 30, 2010. Of these patients, we identified those with a positive MRSA culture from microbiology reports in the VA electronic medical record. We used propensity score matching and multivariable regression models to assess the impact of positive culture on post-discharge outpatient, inpatient, and pharmacy costs and utilization in the 365 days following discharge., Results: Our full cohort included 369,743 inpatients, of whom, 3,599 (1.0%) had positive MRSA cultures. Our final analysis sample included 3,592 matched patients with and without positive cultures. We found that, in the 12 months following hospital discharge, having a positive culture resulted in increases in post-discharge pharmacy costs ($776, P<.0001) and inpatient costs ($12,167, P<.0001). Likewise, having a positive culture increased the risk of a readmission (odds ratio [OR]=1.396, P<.0001), the number of prescriptions (incidence rate ratio [IRR], 1.138; P<.0001) and the number of inpatient days (IRR, 1.204; P<.0001,) but decreased the number of subsequent outpatient encounters (IRR, 0.941; P<.008)., Conclusions: The results of this study indicate that MRSA infections are associated with higher levels of post-discharge healthcare cost and utilization. These findings indicate that financial benefits resulting from infection prevention efforts may extend beyond the initial hospital stay.

Background: Comparison of antimicrobial de-escalation rates between healthcare settings is problematic. To objectively and electronically measure de-escalation a method based upon the spectrum of antimicrobial regimens administered (i.e., spectrum score) was developed., Methods: A Delphi process was used to develop applicable concepts. Spectrum scores were created for 27 antimicrobials based upon susceptibility for 19 organisms. National VA susceptibility data was used to estimate microbial spectrum. Susceptibility estimates were converted to ordinal scores, and values for organisms with multi-drug resistance potential were weighted more heavily. Organism scores were summed to create antibiotic-specific spectrum scores and extended mathematically to score multi-antimicrobial regimens. Vignettes were created from antimicrobial regimens administered to 300 patients hospitalized with pneumonia. Daily spectrum scores were calculated for each case. Hospitalization day 4 scores were subtracted from day 2 scores (i.e., spectrum score ∆). A positive spectrum score ∆ defined de-escalation. Experts ranked each pneumonia case on a 7-point Likert scale (Likert >4 indicated de-escalation). Spectrum score ∆s were compared to expert review. Findings were used to identify score deficiencies. Next, 40 pairs of cases were modified to include antimicrobial administration routes. Each pair contained almost similar regimens; however, one contained oral (PO) the other only intravenous (IV) antimicrobials on day 4 of therapy. Experts reviewed cases as described. Spectrum score ∆ credits to account for PO conversion were derived from the mean paired differences in Likert Score. De-escalation status was evaluated in 100 vignettes containing antimicrobial route by different experts and compared to the modified method., Results: Initial sensitivity and specificity of the spectrum score ∆ to detect expert classified de-escalation events was 86.3 and 96.0%, respectively. In paired cases, the mean (± SD) Likert score was 5.0 (1.5) and 4.6 (1.5) for PO and IV (P = 0.002), respectively. To improve de-escalation event detection, two credits were added to spectrum score ∆s based upon the percentage of antimicrobials administered PO on day 4. The final method, exhibited sensitivity and specificity to detect expert classified de-escalation events of 96.2 and 93.6%, respectively., Conclusions: The final spectrum score method exhibited excellent agreement with expert judgments of de-escalation events in pneumonia.

Objectives: To assess rates of starting or stopping antibiotics across different hospitals., Methods: We used barcode medication administration data to measure antibiotic use on acute-care wards in 128 Veterans Affairs medical centres (VAMCs) in 2010. A treatment day (TD) was defined as the administration of any antibiotic on a given day. A treatment period (TP) was defined as an interval of inpatient antimicrobial therapy with gaps of ≤1 day in TDs. The rate of starting antibiotics was calculated for inpatients who had not yet started antibiotics, as the number of start events divided by the 'person-time at risk'. The rate of stopping antibiotics was calculated analogously for inpatients that were on antibiotics. Once individuals had stopped antibiotics they were removed from further analysis. Per-day start and stop rates were also calculated for each day of hospitalization., Results: The hospital mean rate of starting the first TP was 18.1 start events/100 days at risk (range 8.4-25.6/100 days at risk). The mean hospital stopping rate was 21.1 stop events/100 days at risk (range 13.3-29.5/100 days at risk). The ratio of a facility's starting and stopping rates was highly correlated with overall antibiotic use in TDs/1000 patient-days (rs=0.92, P<0.001), while starting and stopping rates individually were only moderately correlated (rs=0.39, P<0.001)., Conclusions: VAMCs with similar antibiotic use showed marked differences in their starting and stopping rates of antibiotics. It may be useful to target empirical therapy when starting rates are high and definitive therapy when stopping rates are low., (Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy 2014. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Background: Surveillance at hospital admission for multidrug-resistant (MDR) gram-negative bacteria (GNB) is not often performed, potentially leaving patients carrying these organisms unrecognized and not placed in transmission precautions until they develop infection. Veterans Affairs (VA) facilities screen all admissions for methicillin-resistant Staphylococcus aureus (MRSA) and place positive patients in contact precautions. We assessed how often patients with MDR GNB in clinical cultures obtained within 30 days following admission would have been in contact precautions because of a positive MRSA admission screen., Methods: MRSA screening and MDR GNB culture results were extracted from a database of patients admitted to all VA acute care medical facilities from January 2009-December 2012., Results: Of patients with MDR GNB-positive cultures within 30 days following admission, up to 44.3% (dependent on bacterial species) would have been in contact precautions because of a clinical positive admission MRSA nasal screen. Admissions with a positive MRSA screen had odds for MDR GNB in a culture 2.5 times greater than those with a negative screen (95% confidence interval [CI], 2.4-2.6). Odds ratios were 2.4 (95% CI, 2.3-2.5) for MDR Enterobacteriaceae, 2.7 (95% CI, 2.5-2.9) for MDR Pseudomonas aeruginosa, and 4.3 (95% CI, 3.8-4.8) for MDR Acinetobacter spp., Conclusions: Patients may be serendipitously placed in contact precautions for MDR GNB when isolated for a positive admission MRSA screen., (Published by Elsevier Inc.)

Background: Although many studies have estimated the impact of health care-associated methicillin-resistant Staphylococcus aureus (MRSA) infections on mortality during initial hospitalization, little is known about the long-term risk of death in these patients. The purpose of this study was to quantify the effect of MRSA health care-acquired infections (HAIs) on mortality after hospital discharge., Methods: Our study cohort consisted of patients with inpatient admission within the U.S. Department of Veterans Affairs system between October 1, 2007, and September 30, 2010. Of these patients, we identified those with a positive MRSA culture from electronic microbiology reports. We constructed multivariable Cox proportional hazards regressions to assess the impact of a positive culture on postdischarge mortality in the 365 days following discharge using both the full cohort and a propensity score-matched subsample., Results: In our analysis cohort of 369,743 inpatients, positive MRSA cultures were recorded in 3,599 (1.0%) patients. We found that positive cultures resulted in an increased risk of postdischarge mortality both in the full cohort (hazard ratio = 1.42, P < .001) and in the subset of propensity score-matched patients (hazard ratio = 1.37, P < .0001)., Conclusion: We found that MRSA HAIs significantly elevate the long-term risk of mortality. These results underscore the importance of infection prevention efforts in the hospital., (Published by Elsevier Inc.)

Assessment of vital signs is an essential part of surveillance of critically ill patients to detect condition changes and clinical deterioration. While most modern electronic medical records allow for vitals to be recorded in a structured format, the frequency and quality of what is electronically stored may differ from how often these measures are actually recorded. We created a tool that extracts blood pressure, heart rate, temperature, respiratory rate, blood oxygen saturation, and pain level from nursing and other clinical notes recorded in the course of inpatient care to supplement structured vital sign data.

Objectives: After the implementation of an active surveillance programme for MRSA in US Veterans Affairs (VA) Medical Centers, there was an increase in vancomycin use. We investigated whether positive MRSA admission surveillance tests were associated with MRSA-positive clinical admission cultures and whether the availability of surveillance tests influenced prescribers' ability to match initial anti-MRSA antibiotic use with anticipated MRSA results from clinical admission cultures., Methods: Analyses were based on barcode medication administration data, microbiology data and laboratory data from 129 hospitals between January 2005 and September 2010. Hospitalized patient admissions were included if clinical cultures were obtained and antibiotics started within 2 days of admission. Mixed-effects logistic regression was used to examine associations between positive MRSA admission cultures and (i) admission MRSA surveillance test results and (ii) initial anti-MRSA therapy., Results: Among 569,815 included admissions, positive MRSA surveillance tests were strong predictors of MRSA-positive admission cultures (OR 8.5; 95% CI 8.2-8.8). The negative predictive value of MRSA surveillance tests was 97.6% (95% CI 97.5%-97.6%). The diagnostic OR between initial anti-MRSA antibiotics and MRSA-positive admission cultures was 3.2 (95% CI 3.1-3.4) for patients without surveillance tests and was not significantly different for admissions with surveillance tests., Conclusions: The availability of nasal MRSA surveillance tests in VA hospitals did not seem to improve the ability of prescribers to predict the necessity of initial anti-MRSA treatment despite the high negative predictive value of MRSA surveillance tests. Prospective trials are needed to establish the safety and effectiveness of using MRSA surveillance tests to guide antibiotic therapy., (Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy 2014. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Objective: Development of a numerical score to measure the microbial spectrum of antibiotic regimens (spectrum score) and method to identify antibiotic de-escalation events based on application of the score., Design: Web-based modified Delphi method., Participants: Physician and pharmacist antimicrobial stewards practicing in the United States recruited through infectious diseases-focused listservs., Methods: Three Delphi rounds investigated: organisms and antibiotics to include in the spectrum score, operationalization of rules for the score, and de-escalation measurement. A 4-point ordinal scale was used to score antibiotic susceptibility for organism-antibiotic domain pairs. Antibiotic regimen scores, which represented combined activity of antibiotics in a regimen across all organism domains, were used to compare antibiotic spectrum administered early (day 2) and later (day 4) in therapy. Changes in spectrum score were calculated and compared with Delphi participants' judgments on de-escalation with 20 antibiotic regimen vignettes and with non-Delphi steward judgments on de-escalation of 300 pneumonia regimen vignettes. Method sensitivity and specificity to predict expert de-escalation status were calculated., Results: Twenty-four participants completed all Delphi rounds. Expert support for concepts utilized in metric development was identified. For vignettes presented in the Delphi, the sign of change in score correctly classified de-escalation in all vignettes except those involving substitution of oral antibiotics. The sensitivity and specificity of the method to identify de-escalation events as judged by non-Delphi stewards were 86.3% and 96.0%, respectively., Conclusions: Identification of de-escalation events based on an algorithm that measures microbial spectrum of antibiotic regimens generally agreed with steward judgments of de-escalation status.

Background: Antibiotics are essential to effectively treat many hospitalized patients. However, when antibiotics are prescribed incorrectly, they offer little benefit to patients and potentially expose them to risks for complications, including Clostridium difficile infection (CDI) and antibiotic-resistant infections. Information is needed on the frequency of incorrect prescribing in hospitals and how improved prescribing will benefit patients., Methods: A national administrative database (MarketScan Hospital Drug Database) and CDC's Emerging Infections Program (EIP) data were analyzed to assess the potential for improvement of inpatient antibiotic prescribing. Variability in days of therapy for selected antibiotics reported to the National Healthcare Safety Network (NHSN) antimicrobial use option was computed. The impact of reducing inpatient antibiotic exposure on incidence of CDI was modeled using data from two U.S. hospitals., Results: In 2010, 55.7% of patients discharged from 323 hospitals received antibiotics during their hospitalization. EIP reviewed patients' records from 183 hospitals to describe inpatient antibiotic use; antibiotic prescribing potentially could be improved in 37.2% of the most common prescription scenarios reviewed. There were threefold differences in usage rates among 26 medical/surgical wards reporting to NHSN. Models estimate that the total direct and indirect effects from a 30% reduction in use of broad-spectrum antibiotics will result in a 26% reduction in CDI., Conclusions: Antibiotic prescribing for inpatients is common, and there is ample opportunity to improve use and patient safety by reducing incorrect antibiotic prescribing. Implications for Public Health: Hospital administrators and health-care providers can reduce potential harm and risk for antibiotic resistance by implementing formal programs to improve antibiotic prescribing in hospitals.

Background: The study of hospital methicillin-resistant Staphylococcus aureus (MRSA) epidemiology is complicated by its transmissibility. Our objective was to understand how MRSA importation and transmission influence MRSA nosocomial infections in Veterans Affairs Medical Centers (VAMCs)., Methods: We performed hospital-level analyses of acute-care MRSA admission prevalence, acquisition rates, and incident nosocomial clinical culture (INCC) rates, each a surrogate measure of importation, transmission, and nosocomial infection, respectively. We studied 112 VAMCs from October 2007 through September 2010, after the start of a bundled intervention including active surveillance for MRSA. We analyzed data using generalized linear mixed models., Results: A total of 2.9 million surveillance tests were collected from 1.4 million patient admissions. Overall MRSA admission prevalence was 11.4%, acquisition was 5.2 per 1000 patient-days at risk, and INCC was 1.8 per 1000 patient-days at risk. A 10% increase in a hospital's average admission prevalence was associated with a 9.7% increase in its weekly acquisition rates (P < .001) and a 9.8% increase in its weekly INCC rates (P < .001). Significant decreases were observed in all 3 measures during the study period (P < .001). When INCC rates were stratified by nasal MRSA carriage at admission, a significant downward trend was observed only among those initially negative., Conclusions: Measured associations between MRSA admission prevalence, acquisition rate, and INCC rate were consistent with the hypothesis that decreased acquisition led to decreased importation, which in turn further abated acquisition. The downward trend in INCC rate specifically among individuals with negative admission surveillance tests suggests that decreasing transmission contributed to lower rates of nosocomial MRSA infection.

Background: Clostridium difficile is one of the most common and important nosocomial pathogens, causing severe gastrointestinal disease in hospitalized patients. Although "bundled" interventions have been proposed and promoted, optimal control strategies remain unknown., Methods: We designed an agent-based computer simulation of nosocomial C. difficile transmission and infection, which included components such as: patients and health care workers, and their interactions; room contamination via C. difficile shedding; C. difficile hand carriage and removal via hand hygiene; patient acquisition of C. difficile via contact with contaminated rooms or health care workers; and patient antimicrobial use. We then introduced six interventions, alone and "bundled" together: aggressive C. difficile testing; empiric isolation and treatment of symptomatic patients; improved adherence to hand hygiene and contact precautions; improved use of soap and water for hand hygiene; and improved environmental cleaning. All interventions were tested using values representing base-case, typical intervention, and optimal intervention scenarios., Findings: In the base-case scenario, C. difficile infection rates ranged from 8-21 cases/10,000 patient-days, with a case detection fraction between 32%-50%. Implementing the "bundle" at typical intervention levels had a large impact on C. difficile acquisition and infection rates, although intensifying the intervention to optimal levels had much less additional impact. Most of the impact came from improved hand hygiene and empiric isolation and treatment of suspected C. difficile cases., Conclusion: A "bundled" intervention is likely to reduce nosocomial C. difficile infection rates, even under typical implementation conditions. Real-world implementation of the "bundle" should focus on those components of the intervention that are likely to produce the greatest impact on C. difficile infection rates, such as hand hygiene and empiric isolation and treatment of suspected cases.

Objectives: Currently used metrics for antibiotic utilization are not linked to a diagnosis and may be difficult to interpret. We aimed to describe patterns and variation in antibiotic management of three common infectious disease diagnoses in Veterans Affairs Medical Centers (VAMCs)., Methods: This descriptive retrospective cohort study included all veterans discharged between 2007 and 2009 after an acute care admission to a VAMC and a principal ICD-9-CM code for pneumonia (PNEU), skin and soft-tissue infections (SSTI), urinary tract infections (UTI) or non-infectious disease-related diagnoses (NON&#95;INF). Systemic antibiotic use was assessed based on barcode medication administration data. A treatment period was defined as a time of uninterrupted inpatient antibiotic therapy with no gaps of >1 calendar day., Results: Over the study period there were 1.44 million discharges with an acute care admission to 128 VAMCs included in the study. Of the discharges, 58 118 had a primary ICD-9-CM diagnosis classifiable as PNEU, 36 797 as SSTI, 30 223 as UTI and 1 243 098 as NON&#95;INF. Empirical antibiotic use during the first 2 hospital days was frequent for all infectious disease diagnoses. Type of empirical coverage varied among facilities for all conditions, as did treatment durations. Roughly half of all empirical courses of therapy where the patient was still hospitalized on day 4 did not exhibit any change to the antibiotic regimen., Conclusions: There is substantial variation in the management of common infectious diseases with regard to choice of empirical agents and duration of therapy. Diagnosis-specific antibiotic use metrics may prove useful for antibiotic stewardship programmes.

Introduction: Hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA) infections remain one of the leading causes of preventable patient mortality in the US. Eradication of MRSA through decolonization could prevent both MRSA infections and transmission; however, there is currently no consensus within the infectious disease community on the proper role of decolonization in the prevention of infections. The purpose of this study was to assess the impact of decolonization with mupirocin on subsequent MRSA carriage., Methods: Patients included in this study were those with an inpatient admission to a Department of Veterans Affairs (VA) hospital between January 1, 2008 and December 31, 2009 who had a positive MRSA screen on admission and a subsequent re-admission during the same time period. Exposure to mupirocin on the initial hospital admission was measured using Barcode Medication Administration data and MRSA carriage was measured using microbiology text reports and lab data containing results from surveillance swabs collected from the nares. Chi-square tests were used to test for differences in re-admission MRSA carriage rates between mupirocin-receiving and non-mupirocin-receiving patients., Results: Of the 25,282 MRSA-positive patients with a subsequent re-admission included in the present study cohort, 1,183 (4.7%) received mupirocin during their initial hospitalization. Among the patients in the present study cohort who were re-admitted within 30 days, those who received mupirocin were less likely to test positive for MRSA carriage than those who did not receive mupirocin (27.2% vs. 55.1%, P < 0.001). The proportion of those who tested positive for MRSA during re-admissions that occurred 30-60 days, 60-120 days, and >120 days were 33.9, 37.3, and 41.0%, respectively, among mupirocin patients and 52.7%, 53.0%, and 51.9%, respectively, for patients who did not receive mupirocin (P < 0.001 at each time point)., Conclusion: Patients decolonized with mupirocin in VA hospitals were less likely to be colonized with MRSA on re-admission as long as 4 months after decolonization.

Background: Accurate information is needed to direct healthcare systems' efforts to control methicillin-resistant Staphylococcus aureus (MRSA). Assembling complete and correct microbiology data is vital to understanding and addressing the multiple drug-resistant organisms in our hospitals., Methods: Herein, we describe a system that securely gathers microbiology data from the Department of Veterans Affairs (VA) network of databases. Using natural language processing methods, we applied an information extraction process to extract organisms and susceptibilities from the free-text data. We then validated the extraction against independently derived electronic data and expert annotation., Results: We estimate that the collected microbiology data are 98.5% complete and that methicillin-resistant Staphylococcus aureus was extracted accurately 99.7% of the time., Conclusions: Applying natural language processing methods to microbiology records appears to be a promising way to extract accurate and useful nosocomial pathogen surveillance data. Both scientific inquiry and the data's reliability will be dependent on the surveillance system's capability to compare from multiple sources and circumvent systematic error. The dataset constructed and methods used for this investigation could contribute to a comprehensive infectious disease surveillance system or other pressing needs.

Background: Little is known about the implementation of infection control (IC) programs and information technology (IT) infrastructure in long-term care facilities (LTCFs). We assessed the IC human resources, IT infrastructure, and IC scope of practice at LTCFs in Utah., Methods: All LTCFs throughout Utah (n = 80) were invited to complete a written survey in 2005 regarding IC staffing, policies and practices, and IT infrastructure and capacity., Results: Responses were received from 62 facilities (77.5%). Most infection preventionists (IPs) were registered nurses (71%) with on-the-job training (81.7%). Most had other duties besides their IC work (93.5%), which took up the majority of their time. Most facilities provided desktop computers (96.8%) and all provided Internet access, but some of the infrastructure was not current. A minority (14.5%) used sophisticated software packages to support their IC activities. Less than 20% of the facilities had integrated radiology, diagnostic laboratory, or microbiology data with their facility computer system. The Internet was used primarily as a reference tool (77.4%). Most IPs reported taking responsibility for routine surveillance and monitoring tasks, but a substantial number did not perform all queried tasks. They may have difficulty with feedback of specific unit and physician infection rates (43.2% and 67.7%, respectively)., Conclusions: Our findings underscore what has previously been reported about LTCFs' IC human resources and IP scope of practice. We also found that some IT infrastructure was outdated, and that existing resources were underutilized for IC purposes., (Published by Mosby, Inc.)

Objectives: To assess the prevalence of, and the variation in, avoidable use of metronidazole in the Veterans Affairs (VA) healthcare system, Methods: Barcode Medication Administration (BCMA) data were retrospectively assessed for all patients hospitalized between January 2006 and December 2010 in acute-care wards of all VA medical centres (VAMCs) with complete BCMA data and at least 10 acute-care non-intensive care unit (ICU) beds. Potentially avoidable metronidazole days of therapy (DOT) were defined as the administration of metronidazole with another anti-anaerobic antibiotic on the same day for at least two consecutive days during the same hospitalization. Metronidazole was not considered redundant in combination with another anti-anaerobic agent within 28 days after a positive test for Clostridium difficile and during hospitalizations associated with discharge diagnosis codes for cholecystitis or cholangitis., Results: A total of 128 VAMCs satisfied the inclusion criteria. Over the study period there were a total of 782,821 DOT of metronidazole (57.4 DOT per 1000 patient-days), of which 183,267 (23.4%) fulfilled the criteria for avoidable metronidazole DOT. The percentage of avoidable metronidazole DOT remained stable over the study period (22.8% in 2006 and 22.9% in 2010) despite a decrease in overall metronidazole use. There was wide variation in the percentage of avoidable metronidazole DOT among facilities (2010: median 20.3%, IQR 15.3%-29.4%). Piperacillin/tazobactam was the most commonly administered drug on avoidable metronidazole DOT (56.8%)., Conclusions: Potentially avoidable use of metronidazole affected about a quarter of all days when metronidazole was given. The combination of metronidazole with piperacillin/tazobactam was particularly common and represents a possible target for antibiotic stewardship interventions.

Objective: To estimate avoidable intravenous (IV) fluoroquinolone use in Veterans Affairs (VA) hospitals., Design: A retrospective analysis of bar code medication administration (BCMA) data., Setting: Acute care wards of 128 VA hospitals throughout the United States., Methods: Data were analyzed for all medications administered on acute care wards between January 1, 2006, and December 31, 2010. Patient-days receiving therapy were expressed as fluoroquinolone-days (FD) and divided into intravenous (IV; all doses administered intravenously) and oral (PO; at least one dose administered per os) FD. We assumed IV fluoroquinolone use to be potentially avoidable on a given IV FD when there was at least 1 other medication administered via the enteral route., Results: Over the entire study period, 884,740 IV and 830,572 PO FD were administered. Overall, avoidable IV fluoroquinolone use accounted for 46.8% of all FD and 90.9% of IV FD. Excluding the first 2 days of all IV fluoroquinolone courses and limiting the analysis to the non-ICU setting yielded more conservative estimates of avoidable IV use: 20.9% of all FD and 45.9% of IV FD. Avoidable IV use was more common for levofloxacin and more frequent in the ICU setting. There was a moderate correlation between avoidable IV FD and total systemic antibiotic use (r = 0.32)., Conclusions: Unnecessary IV fluoroquinolone use seems to be common in the VA system, but important variations exist between facilities. Antibiotic stewardship programs could focus on this patient safety issue as a "low-hanging fruit" to increase awareness of appropriate antibiotic use.

Multidrug-resistant (MDR) and carbapenem-resistant (CR) Gram-negative pathogens are becoming increasingly prevalent around the globe. Polymyxins and tigecycline are among the few antibiotics available to treat infections with these bacteria but little is known about the frequency of their use. We therefore aimed to estimate the parenteral use of these two drugs in Veterans Affairs medical centers (VAMCs) and to describe the pathogens associated with their administration. For this purpose we retrospectively analyzed barcode medication administration data of parenteral administrations of polymyxins and tigecycline in 127 acute-care VAMCs between October 2005 and September 2010. Overall, polymyxin and tigecycline use were relatively low at 0.8 days of therapy (DOT)/1000 patient days (PD) and 1.6 DOT/1000PD, respectively. Use varied widely across facilities, but increased overall during the study period. Eight facilities accounted for three-quarters of all polymyxin use. The same statistic for tigecycline use was twenty-six VAMCs. There were 1,081 MDR or CR isolates during 747 hospitalizations associated with polymyxin use (1.4/hospitalization). For tigecycline these number were slightly lower: 671 MDR or CR isolates during 500 hospitalizations (1.3/hospitalization) (p = 0.06). An ecological correlation between the two antibiotics and combined CR and MDR Gram-negative isolates per 1000PD during the study period was also observed (Pearson's correlation coefficient r = 0.55 polymyxin, r = 0.19 tigecycline). In summary, while polymyxin and tigecycline use is low in most VAMCs, there has been an increase over the study period. Polymyxin use in particular is associated with the presence of MDR Gram-negative pathogens and may be useful as a surveillance measure in the future.

Background: Natural Language Processing (NLP) systems can be used for specific Information Extraction (IE) tasks such as extracting phenotypic data from the electronic medical record (EMR). These data are useful for translational research and are often found only in free text clinical notes. A key required step for IE is the manual annotation of clinical corpora and the creation of a reference standard for (1) training and validation tasks and (2) to focus and clarify NLP system requirements. These tasks are time consuming, expensive, and require considerable effort on the part of human reviewers., Methods: Using a set of clinical documents from the VA EMR for a particular use case of interest we identify specific challenges and present several opportunities for annotation tasks. We demonstrate specific methods using an open source annotation tool, a customized annotation schema, and a corpus of clinical documents for patients known to have a diagnosis of Inflammatory Bowel Disease (IBD). We report clinician annotator agreement at the document, concept, and concept attribute level. We estimate concept yield in terms of annotated concepts within specific note sections and document types., Results: Annotator agreement at the document level for documents that contained concepts of interest for IBD using estimated Kappa statistic (95% CI) was very high at 0.87 (0.82, 0.93). At the concept level, F-measure ranged from 0.61 to 0.83. However, agreement varied greatly at the specific concept attribute level. For this particular use case (IBD), clinical documents producing the highest concept yield per document included GI clinic notes and primary care notes. Within the various types of notes, the highest concept yield was in sections representing patient assessment and history of presenting illness. Ancillary service documents and family history and plan note sections produced the lowest concept yield., Conclusion: Challenges include defining and building appropriate annotation schemas, adequately training clinician annotators, and determining the appropriate level of information to be annotated. Opportunities include narrowing the focus of information extraction to use case specific note types and sections, especially in cases where NLP systems will be used to extract information from large repositories of electronic clinical note documents.

The clinical presentation and disease course of tuberculosis (TB) in a solid-organ transplant (SOT) recipient may be atypical and the risk of mortality is high. Herein we examine the role of the different tests used in diagnosis of TB and review the specifics of anti-mycobacterial therapy and the public health implications of TB in a SOT recipient.