Risk Factors For Infection In Patients Research Articles

MP16-08 MAJOR SHIFT IN ANTIBIOTIC PROPHYLAXIS PATTERNS FOLLOWING IMPLEMENTATION OF GUIDELINES BASED CYSTOSCOPY SURVEY

You have accessJournal of UrologyCME1 May 2022MP16-08 MAJOR SHIFT IN ANTIBIOTIC PROPHYLAXIS PATTERNS FOLLOWING IMPLEMENTATION OF GUIDELINES BASED CYSTOSCOPY SURVEY Kelly R. Pekala, Danielle Sharbaugh, Jonathan G. Yabes, Adam J. Sharbaugh, Michelle Yu, Valentina Grajales, Oluwaseun Orikogbo, Hermoon Worku, Jordan M. Hay, Toby S. Zhu, Kody M. Armann, Chandler N. Hudson, Benjamin J. Davies, and Bruce L. Jacobs Kelly R. PekalaKelly R. Pekala More articles by this author , Danielle SharbaughDanielle Sharbaugh More articles by this author , Jonathan G. YabesJonathan G. Yabes More articles by this author , Adam J. SharbaughAdam J. Sharbaugh More articles by this author , Michelle YuMichelle Yu More articles by this author , Valentina GrajalesValentina Grajales More articles by this author , Oluwaseun OrikogboOluwaseun Orikogbo More articles by this author , Hermoon WorkuHermoon Worku More articles by this author , Jordan M. HayJordan M. Hay More articles by this author , Toby S. ZhuToby S. Zhu More articles by this author , Kody M. ArmannKody M. Armann More articles by this author , Chandler N. HudsonChandler N. Hudson More articles by this author , Benjamin J. DaviesBenjamin J. Davies More articles by this author , and Bruce L. JacobsBruce L. Jacobs More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002549.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Inappropriate antibiotic administration has a host of well-defined deleterious downstream effects. The American UrologicalAssociation (AUA) released antibiotic guidelines for cystoscopy in June 2019 that recommended oral antibiotics only if there is a break in the mucosal barrier and fluoroquinolones were no longer the antibiotic of choice. As a result, we created a novel clinic-based rapid survey to increase AUA antibiotic guideline adherence. METHODS: To obtain baseline data, we retrospectively reviewed the urology clinic schedule for three-months and identified all patients who underwent cystoscopy. We then completed a literature review and designed a cystoscopy survey based on previous protocols and AUA guidelines to identify patients at high risk of infection. We then implemented a multi-pronged intervention for a twelve-month period where we provided a ‘formal’ grand rounds presentation, ad hoc emails with individual updates, monthly progress reports, edited the electronic health record cystoscopy order set, educated clinic staff, and started using the cystoscopy survey. We then recorded antibiotics given for prophylaxis at time of procedure, individual patient risk factors for infection, 30-day infection outcomes, and urine culture data both pre-intervention and post-intervention. RESULTS: We identified 473 cystoscopies pre-intervention, 2,137 cystoscopies in the intervention, and 417 cystoscopies post-intervention. There was a 30% decrease in the total amount of antibiotics administered and infection rates did not increase. We found that 99% of patients were administered antibiotics pre-intervention, the majority of which were fluoroquinolones. During and after the intervention phase, fluoroquinolone use decreased significantly to 15% and 6.5% respectively. (Figure 1) The utilization rates of recommended antibiotics increased to 91% and persisted post-intervention. CONCLUSIONS: We found that implementation of a cystoscopy survey enabled rapid adoption of new AUA guidelines on antibiotic prophylaxis for cystoscopy, which resulted in a drastic reduction in the amount of antibiotics administered without a spike in infection rates. The use of recommended antibiotics improved dramatically during the intervention period and persisted post-intervention. Source of Funding: Bruce L. Jacobs, MD, MPH is supported in part by the Shadyside Hospital Foundation © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e277 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kelly R. Pekala More articles by this author Danielle Sharbaugh More articles by this author Jonathan G. Yabes More articles by this author Adam J. Sharbaugh More articles by this author Michelle Yu More articles by this author Valentina Grajales More articles by this author Oluwaseun Orikogbo More articles by this author Hermoon Worku More articles by this author Jordan M. Hay More articles by this author Toby S. Zhu More articles by this author Kody M. Armann More articles by this author Chandler N. Hudson More articles by this author Benjamin J. Davies More articles by this author Bruce L. Jacobs More articles by this author Expand All Advertisement PDF DownloadLoading ...

Surgical Helmet Systems Are Associated With a Lower Rate of Prosthetic Joint Infection After Total Knee Arthroplasty: Combined Results From the New Zealand Joint Registry and Surgical Site Infection Improvement Programme.

This study aimed to identify the risk factors, in particular the use of surgical helmet systems (SHSs), for prosthetic joint infection (PJI) after total knee arthroplasty (TKA). Data recorded by the New Zealand Surgical Site Infection Improvement Programme (SSIIP) and the New Zealand Joint Registry (NZJR) were combined and analyzed. Primary TKA procedures performed between July 2013 and June 2018 that were recorded by both the SSIIP and NZJR were analyzed. Two primary outcomes were measured: (1) PJI within 90 days as recorded by the SSIIP and (2) revision TKA for deep infection within 6 months as recorded by the NZJR. Univariate and multivariate analyses were performed to identify risk factors for both outcomes with results considered significant at P < .05. A total of 19,322 primary TKAs were recorded by both databases in which 97 patients had a PJI within 90 days as recorded by the SSIIP (0.50%), and 90 patients had a revision TKA for deep infection within 6 months (0.47%) as recorded by the NZJR. An SHS was associated with a lower rate of PJI (adjusted odds ratio [OR]= 0.50, P= .008) and revision for deep infection (adjusted OR= 0.55, P= .022) than conventional gowning. Male sex (adjusted OR= 2.6, P < .001) and an American Society of Anesthesiologists score >2 were patient risk factors for infection (OR= 2.63, P < .001 for PJI and OR= 1.75, P=.017 for revision for deep infection). Using contemporary data from the SSIIP and NZJR, the use of the SHS was associated with a lower rate of PJI after primary TKA than conventional surgical gowning. Male sex and a higher American Society of Anesthesiologists score continue to be risk factors for infection.

MP02-16 CONTEMPORARY ANTIBIOTIC PRACTICE PATTERNS AND RATES OF INFECTIOUS COMPLICATIONS IN THE REAL WORLD SETTING

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Practice Patterns, Quality of Life and Shared Decision Making I (MP02)1 Apr 2020MP02-16 CONTEMPORARY ANTIBIOTIC PRACTICE PATTERNS AND RATES OF INFECTIOUS COMPLICATIONS IN THE REAL WORLD SETTING Kelly Pekala*, Anup Shah, Olutiwa Akomolede, Hermoon Worku, Devin Rogers, Jathin Bandari, Benjamin Davies, and Bruce Jacobs Kelly Pekala*Kelly Pekala* More articles by this author , Anup ShahAnup Shah More articles by this author , Olutiwa AkomoledeOlutiwa Akomolede More articles by this author , Hermoon WorkuHermoon Worku More articles by this author , Devin RogersDevin Rogers More articles by this author , Jathin BandariJathin Bandari More articles by this author , Benjamin DaviesBenjamin Davies More articles by this author , and Bruce JacobsBruce Jacobs More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000816.016AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: There is increasing awareness surrounding the unintended deleterious downstream effects of antibiotics such as antibiotic resistance and cancer-specific survival. The American Urological Association recently released guidelines in June of 2019 consistent with more judicious antibiotic use and tailored antibiotic prophylaxis. In anticipation of the changes in antibiotic practice patterns, our objective was to review prior antibiotic practice patterns and infectious rates of three of the most common urologic procedures—cystoscopy, prostate biopsy, and post-prostatectomy catheter removal. METHODS: We retrospectively reviewed the Urology clinic schedule for three months (November 2018-January 2019) for cystoscopy and prostate biopsy and for five months (August 2018-January 2019) for post-prostatectomy catheter removal and identified patients who underwent the procedures of interest. We then recorded antibiotics given for prophylaxis at time of procedure, individual patient risk factors for infection, 30-day infection outcomes, and urine and blood culture data. RESULTS: We identified 550 cystoscopies, 113 prostate biopsies, and 157 post-prostatectomy catheter removals. Antibiotic prophylaxis practices varied widely. (Figure 1). Infection rates for cystoscopy, prostate biopsy, and post-prostatectomy catheter removal were 3.6%, 5.3%, and 7.0%, respectively. Among those who had an infection following cystoscopy, we fitted a multilinear regression analysis and found that indication for cystoscopy (eg. bladder cancer surveillance) (p<0.05), clean intermittent catheterization (p<0.05), indwelling foley catheter (p<0.05) were statistically significant. For post-prostatectomy catheter removal, we performed a logistic regression analysis, and a patient that did not receive antibiotics was 4.3 times more likely to have a urinary tract infection to patients receiving a single dose (p = 0.03). CONCLUSIONS: We found tremendous variation in antibiotic practices within one academic institution. In the future, we will be evaluating the effect of the new guideline changes on antibiotic procedural prophylaxis patterns and infection rates. Source of Funding: Shadyside Hospital Foundation © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e18-e18 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kelly Pekala* More articles by this author Anup Shah More articles by this author Olutiwa Akomolede More articles by this author Hermoon Worku More articles by this author Devin Rogers More articles by this author Jathin Bandari More articles by this author Benjamin Davies More articles by this author Bruce Jacobs More articles by this author Expand All Advertisement PDF downloadLoading ...

An Interdisciplinary Team Decreases Hospital Acquired Infections in HCT Patients

Topic Significance & Study Purpose/Background/Rationale Prevention of healthcare-associated infections (HAI) is a priority of regulatory and national agencies and CMS implemented payment reductions for HAIs as of 2015. Central Line Associated Blood Stream Infections (CLABSI) in hospitalized patients are challenging HAIs that are known to increase lengths of stay, financial burdens, and overall mortality. HAI definitions are based on non-immunocompromised patient populations and immunocompromised patients often have increased reporting for these infections. Our NCCN hospital sought to better describe CLABSIs in our hematopoietic cell transplant (HCT) population to assure appropriate reporting of HAIs and to identify opportunities for quality improvement. Methods, Intervention, & Analysis An interdisciplinary team including the Infection Prevention Medical Director, Infection Preventionists and Physicians, Pharmacist, inpatient Nurse Manager and a Clinical Nurse Specialist met monthly to perform intensive reviews of CLABSI events that occurred on an inpatient HCT unit. The review included patient risk factors for infection and the degree to which nurses followed the central line care bundle. As a result of these reviews, a Staff RN group was formed who were educated to became unit experts on CLABSI and central line care. Subsequently, CLABSI rates reduced by 30%. Findings & Interpretation CLABSI reviews found common organisms across cases, opportunities for improvement in nursing practice as well as trends in patient characteristics where gaps in care may exist. By expanding these reviews to other HAIs, situations where standard definitions may not directly apply were identified, particularly with Clostridium Difficile Infection (CDI). The interdisciplinary CDI review focused on common causes of diarrhea which were then categorized and shared with staff to aid in patient care decisions. Discussion & Implications Intensive review of HAI events and identification of trends in the immunocompromised patient population assures accurate reporting of these cases. Reviews also allow for development of internal classifications of causes and ongoing process improvement in patient care by identifying unique situations leading to those infections. While this process requires resources to perform data collection and to review cases, the subsequent potential improvement in patient care may offset those. Multidisciplinary case review can help to improve practice, decrease infections, and potentially decrease the cost of patient care.

Evaluation of patient risk factors for infection with carbapenem-resistant Enterobacteriaceae

To evaluate risk factors for infection or colonization with carbapenem-resistant Enterobacteriaceae (CRE) to develop an algorithm for targeted CRE screening. We conducted a case-control study of 50 CRE-positive cases and 100 CRE-negative controls to identify risk factors that were significant for CRE infection or colonization. The setting was at an acute care academic hospital. Patients who tested positive for CRE or other microbiological laboratory tests during the study period were included. We reviewed medical records of 50 patients who were CRE-positive and 100 matched controls who had a non-CRE culture at a similar anatomic site within the closest time period to the case's culture date. Risk factors were assessed using logistic regression with SAS 9.4, observing the 95% confidence interval (CI) to determine significance. Significant risk factors for CRE infection or colonization included the use of fluoroquinolones (odds ratio [OR], 3.75; 95% CI, 1.35, 10.38) and cephalosporins (OR, 2.37; 95% CI, 1.17, 4.86). In addition, undergoing an invasive procedure with a scope device was also a significant risk factor for our participants (OR, 4.57; 95% CI, 1.31, 16.02). Significance of these risk factors varied within the community-acquired and hospital-acquired cases. Our results suggest that exposure to certain antimicrobials and invasive procedures with a scope device (endoscopic retrograde cholangiopancreatography, duodenal endoscope) are risk factors for CRE. The findings of significant differences in antimicrobials received highlight the necessity to understand antimicrobial stewardship in the development of CRE colonization and infection. Along with antibiotics, inaccessibility to components within scope devices may be increasing the risk of CRE spread.

Risk factors for periprosthetic infection after reverse shoulder arthroplasty

Management of periprosthetic infection after reverse shoulder arthroplasty (RSA) remains a challenge. Whereas the infection rate after RSA has improved, more information would be helpful to identify patient risk factors for infection after RSA. The purpose of this study was to evaluate risk factors for infection after RSA. We identified 301 primary RSAs with a minimum of 1-year follow-up in a prospectively collected shoulder arthroplasty registry. We performed bivariate and multivariable logistic regression analyses to assess the association between patient demographic and clinical characteristics (age, sex, smoking, diabetes, rheumatoid arthritis, body mass index, and history of prior failed hemiarthroplasty or total shoulder arthroplasty) and periprosthetic infection after RSA. There were 15 periprosthetic infections after RSA (5.0%). Patients with a history of RSA for failed arthroplasty (odds ratio, 5.75; 95% confidence interval, 2.01-16.43; P = .001) and patients younger than 65 years had an increased risk for development of an infection (odds ratio, 4.0; 95% confidence interval, 1.21-15.35; P = .021). History of smoking, diabetes, rheumatoid arthritis, or obesity did not contribute to an increased risk of infection after RSA. This is the first study evaluating risk factors for infection after RSA while controlling for confounding variables with multivariable analysis. The greatest risk factors for infection after RSA were history of a prior failed arthroplasty and age younger than 65 years. Patients with these clinical characteristics should be counseled preoperatively about the increased risk for development of infection after RSA.

Risk factors for infections related to external ventricular drainage.

BACKGROUND External ventricular drainage (EVD) is the most common method of treatment for patients with increased intracranial pressure due to acute hydrocephalus. The most frequent complications of EVD are infections of the central nervous system. Earlier studies indicated numerous risk factors, although the results of studies regarding the impacts of individual factors on the occurrence of infections differ. Our research was aimed at finding the risk factors for infection in patients with an inserted EVD, treated at the Department of Neurosurgery of University Medical Centre (UMC) Ljubljana. METHODS In the article we describe a retrospective research of EVDs inserted in the period from January 2000 to January 2009. Forty-eight cases of EVDs met the study inclusion criteria. Among them, there were 10 cases with an infection which occurred during inserted EVD. We recorded, compared and evaluated information about the patient, the EVD and infections. RESULTS The duration of the drainage was confirmed as a risk factor for EVD infections (p = 0.004). The infection occurred on average on day 8.9 ± 5.4. The shares of subarachnoid and intraventricular hemorrhage, previous neurosurgical procedures, EVD manipulations, number of successive drainages and duration of hospitalization were greater in the cases of infected EVDs. In the cases of EVD exchange, the average day of change in group without infection was day 10.9 ± 5.8 (p = 0.030). Among infectious agents, Gram-positive bacteria prevailed. CONCLUSIONS Strict asepsis is advised during insertion and handling of EVD and a prophylactic exchange of EVD on day 10 of insertion. Risk factors in our study do not differ from findings in other studies. Therefore it is suggested that prophylactic measures against drain-related infection should be developed and implemented and their efficacy confirmed in a prospective study.

Risk Factors for Surgical Site Infections Following Spinal Fusion Procedures: A Case-Control Study

Spinal fusion procedures are associated with a significant rate of surgical site infection (SSI) (1%-12%). The goal of this study was to identify modifiable risk factors for spinal fusion SSIs at a large tertiary care center. A retrospective, case-control (1:3 ratio) analysis of SSIs following posterior spine fusion procedures was performed over a 1-year period. Clinical and surgical data were collected through electronic database and chart review. Variables were evaluated by univariate analysis and multivariable logistic regression. In total, 57 deep SSIs were identified out of 1587 procedures (3.6%). Infections were diagnosed a mean of 13.5 ± 8 days postprocedure. Staphylococcus aureus was the predominant pathogen (63%); 1/3 of these isolates were methicillin resistant. Significant patient risk factors for infection by univariate analysis included ASA score >2 and male gender. Among surgical variables, infected cases had significantly higher proportions of staged procedures and thoracic level surgeries and had a greater number of vertebrae fused. Notably, infected fusion procedures had a longer duration of closed suction drains than controls (5.1 ± 2 days vs 3.4 ± 1 day, respectively; P < .001). Drain duration (unit odds ratio [OR], 1.6 per day drain present; 95% confidence interval [CI], 1.3-1.9), body mass index (OR, 1.1; 95% CI, 1.0-1.1), and male gender (OR, 2.7; 95% CI, 1.4-5.6) were significant risk factors in the multivariate analysis. Prolonged duration of closed suction drains is a strong independent risk factor for SSI following instrumented spinal fusion procedures. Therefore, removing drains as early as possible may lower infection rates.

Antibiotics in head and neck surgery in the setting of malnutrition, tracheotomy, and diabetes

The objectives of this study are to compare short vs. long antibiotic prophylaxis in the setting of malnutrition, diabetes, and tracheotomy. Retrospective chart review. The charts of 407 patients undergoing clean-contaminated head and neck surgery were reviewed for disease type, operation performed, length of antibiotic prophylaxis, wound complications, and length of hospital stay. Three intrinsic patient risk factors for infection (malnutrition, diabetes mellitus, and tracheotomy) were evaluated for an effect on the optimal length of antibiotic prophylaxis. The data was statistically analyzed using the two-tailed Fisher's exact test. Overall, the incidence of infection was 7% in short-course antibiotics and 13% in long-course antibiotics (P = .06). The incidence of infection was 18% in malnourished patients and 3% in well-nourished patients (P < .0001). In malnourished patients, the incidence of infection was 16% in short-course antibiotics and 19% in long-course antibiotics (P = 1). The incidence of infection was 11% in diabetics and 23% in nondiabetics (P = .13). In diabetic patients, the incidence of infection was 0% on short-course antibiotics and 16% on long-course antibiotics (P = .55). The incidence of pneumonia was 14% in patients with tracheotomy and 5% in patients without tracheotomy (P = .0014). In patients with tracheotomy, the incidence of pneumonia was 8% on short-course antibiotics and 15% on long-course antibiotics (P = .6931). Malnutrition and tracheotomy were associated with a higher infection rate while diabetes was not found to be a risk factor. Prolonged antibiotics were not associated with a lower infection rate in the overall group or in any subgroup.

Intra-abdominal infections

The aim of this article is to outline developments in the three cornerstones of treatment of intra-abdominal infections during critical illness: source control; antimicrobial therapy; and mitigation of deranged immune and coagulation responses. Although adequate source control remains the goal of mechanical management of intra-abdominal infections, neither planned re-laparotomy nor open-abdomen management appears to offer a survival benefit as compared with on-demand re-laparotomy. Novel approaches to restoration of a functional gastrointestinal tract have emerged as alternatives to more invasive surgery. A persistent increase in the prevalence of intra-abdominal infections caused by multidrug resistant pathogens has led researchers to investigate shorter-course antimicrobial therapy and other antibiotic administration strategies with encouraging initial results. Therapy with recombinant human activated protein C should now be considered for patients with severe abdominal sepsis associated with a high risk of death. Because randomized controlled trials of intra-abdominal infections involve critically ill patients infrequently, only limited evidence-based recommendations regarding the management of these patients may be drawn. Therapy should focus above all else on timely obtainment of adequate source control, in conjunction with judicious use of antimicrobial therapy dictated by individual patient risk factors for infection with multidrug resistant pathogens.

Article Commentary: Strategies in the Prevention and Management of Ventilator-Associated Pneumonia

Ventilator-associated pneumonia (VAP) is a leading cause of morbidity and mortality in the intensive care unit. Prevention of VAP is possible through the use of several evidence-based strategies intended to minimize intubation, the duration of mechanical ventilation, and the risk of aspiration of oropharyngeal pathogens. Current data favor the quantitative analysis of lower respiratory tract cultures for the diagnosis of VAP, accompanied by the initiation of broad-spectrum empiric antimicrobial therapy based on patient risk factors for infection with multi-drug-resistant pathogens and data from unit-specific antibiograms. Eventual choice of antibiotic and duration of therapy are selected based on culture results and patient stability, with an emphasis on minimization of unnecessary antibiotic use.

Surgical wound infections occurring in day surgery patients

The occurrence of surgical wound infection in outpatient day surgery has not been extensively studied despite the increasing popularity of this mode of treatment. The present study was conducted to determine the frequency of surgical wound infections in a day surgery population. We randomly selected during a 6-month period 635 (25%) of 2540 patients undergoing a day surgery procedure in which a skin incision was made. The patients were telephoned 1 month after their procedure by an infection control practitioner. Infection was diagnosed if the patient reported that (1) their physician had made a diagnosis of a wound infection or (2) pus was or had been issuing from the wound. Of the 515 patients contacted, 72% had undergone a clean and 28% a clean-contaminated procedure. Patient risk factors for infection were almost completely absent in our day surgery patients. Twenty-six wound infections were diagnosed, 19 of which were identified by physicians' diagnosis and 7 by patient description, for a rate of 5.05%. Two patients required hospitalization for their infections, and 14 were treated with antibiotics. The clean wound infection rates were 4.62%, less than half the infection rate seen in our patients undergoing inpatient surgery at 1 month follow-up by the same surveillance technique. We conclude that day surgery infection rates are much lower than inpatient surgery infection rates at our facility, probably because of a relative absence of risk factors in the day surgery patients.