Publications by authors named "Jon P Furuno"

98 Publications

Frequency and Characteristics of Patients Prescribed Antibiotics on Admission to Hospice Care.

J Palliat Med 2021 Nov 24. Epub 2021 Nov 24.

Department of Pharmacy Practice, Oregon State University College of Pharmacy, Portland, Oregon, USA.

Little is known about antibiotic prescribing on hospice admission despite known risks and limited evidence for potential benefits. To describe the frequency and characteristics of patients prescribed antibiotics on hospice admission. Cross-sectional study. Adult (age ≥18 years) decedents of a national, for-profit hospice chain across 19 U.S. states who died between January 1, 2017 and December 31, 2019. The primary outcome was having an antibiotic prescription on hospice admission. Patient characteristics of interest were demographics, hospice referral location, hospice care location, census region, primary diagnosis, and infectious diagnoses on admission. We used multivariable logistic regression to quantify associations between study variables. Among 66,006 hospice decedents, 6080 (9.2%) had an antibiotic prescription on hospice admission. Fluoroquinolones (22%) were the most frequently prescribed antibiotic class. Patients more likely to have an antibiotic prescription on hospice admission included those referred to hospice care from the hospital (adjusted odds ratio [aOR] 1.13, 95% confidence interval [CI] 1.00-1.29) compared with an assisted living facility, those receiving hospice care in a private home (aOR 3.85, 95% CI 3.50-4.24), nursing home (aOR 3.65, 95% CI 3.24-4.11), assisted living facility (aOR 4.04, 95% CI 3.51-4.64), or hospital (aOR 2.43, 95% CI 2.18-2.71) compared with inpatient hospice, and those with a primary diagnosis of liver disease (aOR 2.23, 95% CI 1.82-2.74) or human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) (aOR 3.89, 95% CI 2.27-6.66) compared with those without these diagnoses. Approximately 9% of hospice patients had an antibiotic prescription on hospice admission. Patients referred to hospice from a hospital, those receiving care in a noninpatient hospice facility, and those with liver disease or HIV/AIDS were more likely to have an antibiotic prescription. These results may inform future antimicrobial stewardship interventions among patients transitioning to hospice care.
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http://dx.doi.org/10.1089/jpm.2021.0062DOI Listing
November 2021

Are there sex differences in potentially inappropriate prescribing in adults with multimorbidity?

J Am Geriatr Soc 2021 08 6;69(8):2163-2175. Epub 2021 May 6.

Department of Family Medicine, Oregon Health and Science University, Portland, Oregon, USA.

Background/objectives: Limited knowledge exists regarding sex differences in prescribing potentially inappropriate medications (PIMs) for various multimorbidity patterns. This study sought to determine sex differences in PIM prescribing in older adults with cardiovascular-metabolic patterns.

Design: Retrospective cohort study.

Setting: Health and Retirement Study (HRS) 2004-2014 interview data, linked to HRS-Medicare claims data annualized for 2005-2014.

Study Sample: Six thousand three-hundred and forty-one HRS participants aged 65 and older with two and more chronic conditions.

Measurements: PIM events were calculated using 2015 American Geriatrics Society Beers Criteria. Multimorbidity patterns included: "cardiovascular-metabolic only," "cardiovascular-metabolic plus other physical conditions," "cardiovascular-metabolic plus mental conditions," and "no cardiovascular-metabolic disease" patterns. Logistic regression models were used to determine the association between PIM and sex, including interaction between sex and multimorbidity categories in the model, for PIM overall and for each PIM drug class.

Results: Women were prescribed PIMs more often than men (39.4% vs 32.8%). Overall, women had increased odds of PIM (Adj. odds ratio [OR] = 1.30, 95% confidence interval [CI]: 1.16-1.46). Women had higher odds of PIM than men with cardiovascular-metabolic plus physical patterns (Adj. OR = 1.25, 95% CI: 1.07-1.45) and cardiovascular-metabolic plus mental patterns (Adj. OR = 1.25, 95% CI: 1.06-1.48), and there were no sex differences in adults with a cardiovascular-metabolic only patterns (Adj. OR = 1.13, 95% CI: 0.79-1.62). Women had greater odds of being prescribed the following PIMs: anticholinergics, antidepressants, antispasmodics, benzodiazepines, skeletal muscle relaxants, and had lower odds of being prescribed pain drugs and sulfonylureas compared with men.

Conclusion: This study evaluated sex differences in PIM prescribing among adults with complex cardiovascular-metabolic multimorbidity patterns. The effect of sex varied across multimorbidity patterns and by different PIM drug classes. This study identified important opportunities for future interventions to improve medication prescribing among older adults at risk for PIM.
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http://dx.doi.org/10.1111/jgs.17194DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8373665PMC
August 2021

Interfacility transfer communication of multidrug-resistant organism colonization or infection status: Practices and barriers in the acute-care setting.

Infect Control Hosp Epidemiol 2021 Apr 16:1-6. Epub 2021 Apr 16.

Department of Pharmacy Practice, Oregon State University College of Pharmacy, Portland, Oregon.

Objective: To describe interfacility transfer communication (IFTC) methods for notification of multidrug-resistant organism (MDRO) status in a diverse sample of acute-care hospitals.

Design: Cross-sectional survey.

Participants: Hospitals within the Society for Healthcare Epidemiology of America (SHEA) Research Network (SRN).

Methods: SRN members completed an electronic survey on protocols and methods for IFTC. We assessed differences in IFTC frequency, barriers, and perceived benefit by presence of an IFTC protocol.

Results: Among 136 hospital representatives who were sent the survey, 54 (40%) responded, of whom 72% reported having an IFTC protocol in place. The presence of a protocol did not differ significantly by hospital size, academic affiliation, or international status. Of those with IFTC protocols, 44% reported consistent notification of MDRO status (>75% of the time) to receiving facilities, as opposed to 13% from those with no IFTC protocol (P = .04). Respondents from hospitals with IFTC protocols reported significantly fewer barriers to communication compared to those without (2.8 vs 4.3; P = .03). Overall, however, most respondents (56%) reported a lack of standardization in communication. Presence of an IFTC protocol did not affect whether respondents perceived IFTC protocols as having a significant impact on infection prevention or antimicrobial stewardship.

Conclusions: Most respondents reported having an IFTC protocol, which was associated with reduced communication barriers at transfer. Standardization of protocols and clarity about expectations for sending and receipt of information related to MDRO status may facilitate IFTC and promote appropriate and timely infection prevention practices.
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http://dx.doi.org/10.1017/ice.2021.131DOI Listing
April 2021

Decreasing Trends in Opioid Prescribing on Discharge to Hospice Care.

J Pain Symptom Manage 2021 11 10;62(5):1026-1033. Epub 2021 Apr 10.

Division of General Internal Medicine & Geriatrics, Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA.

Context: There are concerns that policies aimed to prevent opioid misuse may unintentionally reduce access to opioids for patients at end-of-life.

Objective: We assessed trends in opioid prescribing among patients on discharge from the hospital to hospice care.

Methods: This was a retrospective cohort study among adult (age ≥18 years) patients discharged from a 544-576 bed, academic medical center to hospice care between January 1, 2010 to December 31, 2018. Study data were collected from a repository of patients' electronic health record data. Our primary outcome was the frequency of opioid prescribing on discharge to hospice care. Our primary exposure was the calendar year of discharge. We also investigated non-opioid analgesic prescribing and stratified opioid prescribing trends by patient characteristics (e.g., demographics, cancer diagnosis, and location of hospice care).

Results: Among 2,648 discharges to hospice care, mean (standard deviation) age was 65.8 (16.0) years, 46.3% were female, and 58.7% had a cancer diagnosis. Opioid prescribing on discharge to hospice care decreased significantly from 91.2% (95% confidence interval (CI) = 87.1%-94.1%) in 2010 to 79.3% (95% CI = 74.3%-83.5%) in 2018 adjusting for age, sex, cancer diagnosis, and location of hospice care. Prescribing of non-opioid analgesic medications increased over the same time period.

Conclusions: We observed a statistically significant decreasing trend in opioid prescribing on discharge to hospice care. Further research should aim to confirm these findings and to identify opportunities to ensure optimal pain management among patients transitioning to hospice care.
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http://dx.doi.org/10.1016/j.jpainsymman.2021.03.025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8502178PMC
November 2021

Variation in Hospice Patient and Admission Characteristics by Referral Location.

Med Care 2020 12;58(12):1069-1074

Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA.

Background: Little is known regarding differences between patients referred to hospice from different care locations.

Objective: The objective this study was to describe the associations between hospice referral locations and hospice patient and admission characteristics.

Research Design: Cross-sectional analysis of hospice administrative data.

Subjects: Adult (age older than 18 y) decedents of a national, for-profit, hospice chain across 19 US states who died between January 1, 2012, and December 31, 2016.

Measures: Patients' primary hospice diagnosis, hospice length stay, and hospice care site. We also determined the frequency of opioid prescriptions with and without a bowel regimen on hospice admission.

Results: Among 78,647 adult decedents, the mean age was 79.2 (SD=13.5) years, 56.4% were female, and 69.9% were a non-Hispanic White race. Most hospice referrals were from the hospital (51.9%), followed by the community (21.9%), nursing homes (17.4%), and assisted living (8.8%). Cancer (33.6%) was the most prevalent primary hospice diagnosis; however, this varied significantly between referral locations (P<0.001). Similarly, home hospice (32.8%) was the most prevalent site; however, this also varied significantly between referral locations (P<0.001). More hospital-referred patients (55.6%) had a hospice length of stay <7 days compared with patients referred from nursing homes (30.3%), the community (28.9%), or assisted living (18.7%), P<0.001. Hospital-referred patients also had the lowest frequency (58.4%) of coprescribed opioids and bowel regimen on hospice admission compared with other referral locations.

Conclusion: We observed significant differences in hospice patient and admission characteristics by referral location.
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http://dx.doi.org/10.1097/MLR.0000000000001415DOI Listing
December 2020

Opioid prescribing on discharge to skilled nursing facilities.

Pharmacoepidemiol Drug Saf 2020 09 29;29(9):1183-1188. Epub 2020 Jul 29.

Department of Pharmacy Practice, Oregon State University College of Pharmacy, Portland, Oregon, USA.

Purpose: Skilled nursing facility (SNF) residents are at increased risk for opioid-related harms. We quantified the frequency of opioid prescribing among patients discharged from an acute care hospital to SNFs.

Methods: This was a retrospective cohort study among adult (≥18 years) inpatients discharged from a quaternary-care academic referral hospital in Portland, OR to a SNF between January 1, 2017 and December 31, 2018. Our primary outcome was receipt of an opioid prescription on discharge to a SNF. Our exposures included patient demographics (eg, age, sex), comorbid illnesses, surgical diagnosis related group (DRG), receiving opioids on the first day of the index hospital admission, and inpatient hospital length of stay.

Results: Among 4374 patients discharged to a SNF, 3053 patients (70%) were prescribed an opioid on discharge. Among patients prescribed an opioid, 61% were over the age of 65 years, 50% were male, and 58% had a surgical Medicare severity diagnosis related group (MS-DRG). Approximately 70% of patients discharged to a SNF were prescribed an opioid on discharge, of which 68% were for oxycodone, and 52% were for ≥90 morphine milligram equivalents per day. Surgical DRG, diagnoses of cancer or chronic pain, last pain score, and receipt of an opioid on first day of the index hospital admission were independently associated with being prescribed an opioid on discharge to a SNF.

Conclusion: Opioids were frequently prescribed at high doses to patients discharged to a SNF. Efforts to improve opioid prescribing safety during this transition may be warranted.
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http://dx.doi.org/10.1002/pds.5075DOI Listing
September 2020

Health Care Worker Perceptions of Gaps and Opportunities to Improve Hospital-to-Hospice Transitions.

J Palliat Med 2020 07 31;23(7):900-906. Epub 2019 Dec 31.

Department of Pharmacy Practice, Oregon State University College of Pharmacy, Portland, Oregon, USA.

Care transitions from the hospital to hospice are a difficult time, and gaps during this transitions could cause poor care experiences and outcomes. However, little is known about what gaps exist in the hospital-to-hospice transition. To understand the process of hospital-to-hospice transition and identify common gaps in the transition that result in unsafe or poor patient and family caregiver experiences. We conducted a qualitative descriptive study using semistructured interviews with health care workers who are directly involved in hospital-to-hospice transitions. Participants were asked to describe the common practice of discharging patients to hospice or admitting patients from a hospital, and share their observations about hospital-to-hospice transition gaps. Fifteen health care workers from three hospitals and three hospice programs in Portland, Oregon. All interviews were audio recorded and analyzed using qualitative descriptive methods to describe current practices and identify gaps in hospital-to-hospice transitions. Three areas of gaps in hospital-to-hospice transitions were identified: (1) low literacy about hospice care; (2) changes in medications; and (3) hand-off information related to daily care. Specific concerns included hospital providers giving inaccurate descriptions of hospice; discharge orders not including comfort medications for the transition and inadequate prescriptions to manage medications at home; and lack of information about daily care hindering smooth transition and continuity of care. Our findings identify gaps and suggest opportunities to improve hospital-to-hospice transitions that will serve as the basis for future interventions to design safe and high-quality hospital-to-hospice care transitions.
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http://dx.doi.org/10.1089/jpm.2019.0513DOI Listing
July 2020

Several Roads Lead to Rome: Operationalizing Antibiotic Stewardship Programs in Nursing Homes.

J Am Geriatr Soc 2020 01 11;68(1):11-14. Epub 2019 Dec 11.

Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Detroit, Michigan.

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http://dx.doi.org/10.1111/jgs.16279DOI Listing
January 2020

Collaboration Makes Us Better: Time to Increase Equity in the Science of Hospice and Palliative Care.

J Palliat Med 2019 12;22(12):1492

Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado.

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http://dx.doi.org/10.1089/jpm.2019.0348DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6998044PMC
December 2019

Compliance with statewide regulations for communication of patients' multidrug-resistant organism and Clostridium difficile status during transitions of care.

Am J Infect Control 2020 04 8;48(4):451-453. Epub 2019 Oct 8.

Department of Pharmacy Practice, Oregon State University/Oregon Health & Science University College of Pharmacy, Portland, OR. Electronic address:

In 2014, Oregon implemented an interfacility transfer communication law requiring notification of multidrug-resistant organism status on patient transfer. Based on 2015 and 2016 statewide facility surveys, compliance was 77% and 87% for hospitals, and 67% and 68% for skilled nursing facilities. Methods for complying with the rule were heterogeneous, and fewer than half of all facilities surveyed reported use of a standardized interfacility transfer communication form to assess a patient's multidrug-resistant organism status on transfer.
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http://dx.doi.org/10.1016/j.ajic.2019.08.025DOI Listing
April 2020

Frequency and Documentation of Medication Decisions on Discharge from the Hospital to Hospice Care.

J Am Geriatr Soc 2019 06 10;67(6):1258-1262. Epub 2019 Mar 10.

Department of Pharmacy Practice, Oregon State University/Oregon Health & Science University College of Pharmacy, Portland, Oregon.

Objectives: To quantify the frequency and type of medication decisions on discharge from the hospital to hospice care.

Design: Retrospective cohort study.

Setting: A 544-bed academic tertiary care hospital in Portland, Oregon.

Participants: A total of 348 adult patients (age ≥18 y) discharged to hospice care between January 1, 2010, and December 31, 2016.

Measurements: Data were collected from an electronic repository of medical record data and a manual review of patients' discharge summaries. Our outcomes of interest were the frequency and type of medication decisions documented in patients' discharge summaries. Medication decisions were categorized as continuation, continuation but with changes in dose, route of administration, and/or frequency, discontinuation, and initiation of new medications. We also collected data on the frequency of patient/family in the participation of medication-related decisions.

Results: Patients were prescribed a mean of 7.1 medications (standard deviation [SD] = 4.8) on discharge to hospice care. The most prevalent medications prescribed on discharge were strong opioids (82.5%), anxiolytics/sedatives (62.9%), laxatives (57.5%), antiemetics (54.3%), and nonopioid analgesics (45.4%). However, only 67.8% (213/341) of patients who were prescribed an opioid on discharge to hospice care were also prescribed a laxative. Discharging providers made a mean of 15.0 decisions (SD = 7.2) per patient of which 28.5% were to continue medications without changes, 6.7% were to continue medications with changes, 30.3% were to initiate new medications, and 34.5% were to discontinue existing medications. Patients and/or family members were involved in medication decisions during 21.6% of discharges; patients were involved in 15.2% of decisions.

Conclusion: Patients averaged more than 15 medication decisions on discharge to hospice care. However, it was rarely documented that patients and/or their families participated in these decisions. J Am Geriatr Soc, 2019.
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http://dx.doi.org/10.1111/jgs.15860DOI Listing
June 2019

Antibiotic prescribing upon discharge from the hospital to long-term care facilities: Implications for antimicrobial stewardship requirements in post-acute settings.

Infect Control Hosp Epidemiol 2019 01 9;40(1):18-23. Epub 2018 Nov 9.

1Department of Pharmacy Practice,Oregon State University,Oregon Health & Science University College of Pharmacy,Portland,Oregon.

Objective: To quantify the frequency and outcomes of receiving an antibiotic prescription upon discharge from the hospital to long-term care facilities (LTCFs).

Design: Retrospective cohort study.

Setting: A 576-bed, academic hospital in Portland, Oregon.PatientsAdult inpatients (≥18 years of age) discharged to an LTCF between January 1, 2012, and June 30, 2016.

Methods: Our primary outcome was receiving a systemic antibiotic prescription upon discharge to an LTCF. We also quantified the association between receiving an antibiotic prescription and 30-day hospital readmission, 30-day emergency department (ED) visit, and Clostridium difficile infection (CDI) on a readmission or ED visit at the index facility within 60 days of discharge.

Results: Among 6,701 discharges to an LTCF, 22.9% were prescribed antibiotics upon discharge. The most prevalent antibiotic classes prescribed were cephalosporins (20.4%), fluoroquinolones (19.1%), and penicillins (16.7%). The medical records of ~82% of patients included a diagnosis code for a bacterial infection on the index admission. Among patients prescribed an antibiotic upon discharge, the incidence of 30-day hospital readmission to the index facility was 15.9%, the incidence of 30-day ED visit at the index facility was 11.0%, and the incidence of CDI on a readmission or ED visit within 60 days of discharge was 1.6%. Receiving an antibiotic prescription upon discharge was significantly associated with 30-day ED visits (adjusted odds ratio [aOR], 1.2; 95% confidence interval [CI], 1.02-1.5) and with CDI within 60 days (aOR, 1.7; 95% CI, 1.02-2.8) but not with 30-day readmissions (aOR, 1.01; 95% CI, 0.9-1.2).

Conclusions: Antibiotics were frequently prescribed upon discharge to LTCFs, which may be associated with increased risk of poor outcomes post discharge.
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http://dx.doi.org/10.1017/ice.2018.288DOI Listing
January 2019

Clinical Outcomes of Oral Suspension versus Delayed-Release Tablet Formulations of Posaconazole for Prophylaxis of Invasive Fungal Infections.

Antimicrob Agents Chemother 2018 10 24;62(10). Epub 2018 Sep 24.

Department of Pharmacy Practice, Oregon State University/Oregon Health & Science University College of Pharmacy, Portland, Oregon, USA

Posaconazole is used for prophylaxis for invasive fungal infections (IFIs) among patients with hematologic malignancies. We compared the incidence of breakthrough IFIs and early discontinuation between patients receiving delayed-release tablet and oral suspension formulations of posaconazole. This was a retrospective cohort study of patients receiving posaconazole between 1 January 2010 and 30 June 2016. We defined probable or proven breakthrough IFIs using the European Organization for Research and Treatment of Cancer (EORTC) criteria. Overall, 547 patients received 860 courses of posaconazole (53% received the oral suspension and 48% received the tablet); primary indications for prophylaxis were acute myeloid leukemia (69%), graft-versus-host disease (18%), and myelodysplastic syndrome (3%). There were no significant differences in demographics or indications between patients receiving the different formulations. The incidence and incidence rate of probable or proven IFIs were 1.6% and 3.2 per 10,000 posaconazole days, respectively. There was no significant difference in the rate of IFIs between suspension courses (2.8 per 10,000 posaconazole days) and tablet courses (3.7 per 10,000 posaconazole days) (rate ratio = 0.8, 95% confidence interval [CI] = 0.3 to 2.3). Of the 14 proven or probable cases of IFI, 8/14 had posaconazole serum concentrations measured, and the concentrations in 7/8 were above 0.7 μg/ml. Posaconazole was discontinued early in 15.5% of courses; however, the frequency of discontinuation was also not significantly different between the tablet (16.5%) and oral suspension (14.6%) formulations (95% CI for difference = -0.13 to 0.06). In conclusion, the incidence of breakthrough IFIs was low among patients receiving posaconazole prophylaxis and not significantly different between patients receiving the tablet formulation and those receiving the oral suspension formulation.
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http://dx.doi.org/10.1128/AAC.00893-18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6153813PMC
October 2018

Feasibility and Acceptability of Nurse-Led Primary Palliative Care for Older Adults with Chronic Conditions: A Pilot Study.

J Palliat Med 2018 08 24;21(8):1114-1121. Epub 2018 May 24.

5 Division of Pulmonary and Critical Care Medicine, University of Washington , Harborview Medical Center, Seattle, Washington.

Background: Many older adults live with serious illness for years before their death. Nurse-led primary palliative care could improve their quality of life and ability to stay in their community.

Objectives: To assess feasibility and acceptability of a nurse-led Transitional Palliative Care (TPC) program for older adults with serious illness.

Methods: The study was a pilot trial of the TPC program in which registered nurses assisted patients with symptom management, communication with care providers, and advance care planning. Forty-one older adults with chronic conditions were enrolled in TPC or standard care groups. Feasibility was assessed through enrollment and attrition rates and degree of intervention execution. Acceptability was assessed through surveys and exit interviews with participants and intervention nurses.

Results: Enrollment rate for those approached was 68%, and completion rate for those enrolled was 71%. The TPC group found the intervention acceptable and helpful and was more satisfied with care received than the control group. However, one-third of participants perceived that TPC was more than they needed, despite the number of symptoms they experienced and the burdensomeness of their symptoms. More than half of the participants had little to no difficulty participating in daily activities.

Conclusion: This study demonstrated that the nurse-led TPC program is feasible, acceptable, and perceived as helpful. However, further refinement is needed in selection criteria to identify the population who would most benefit from primary palliative care before future test of the efficacy of this intervention.
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http://dx.doi.org/10.1089/jpm.2017.0666DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6916529PMC
August 2018

Clinical Intentions of Antibiotics Prescribed Upon Discharge to Hospice Care.

J Am Geriatr Soc 2018 03 18;66(3):565-569. Epub 2018 Jan 18.

Department of Pharmacy Practice, College of Pharmacy, Oregon State University/Oregon Health & Science University, Portland, Oregon.

Objectives: To better understand the clinical intentions for antibiotic prescribing upon discharge from acute care to hospice care.

Design: Retrospective cohort study.

Setting: Five hundred forty-four-bed academic, acute-care, tertiary referral hospital in Portland, Oregon.

Participants: Adults (≥18) who received an outpatient prescription for antibiotics on discharge from an acute care hospital to hospice care between January 1, 2009 and December 31, 2011 (N = 149).

Measurements: We determined whether antibiotics were indicated for treatment of an active infection, palliative treatment, prophylaxis, or prescribed according to family or participant preference.

Results: Antibiotics were prescribed to 17.6% (n = 149) of individuals discharged to hospice care over the 3-year study period. Antibiotics were most frequently prescribed for pneumonia (19.5%), urinary tract infections (18.9%), and gastrointestinal tract infections (17.0%). The explicit rationale for antibiotic prescription was documented for only 72 prescriptions (45.3%). For 84 (52.8%) participants, antibiotics were used to treat an active infection in the hospital. Of prescriptions with a documented rationale, 37.5% indicated that the intent was curative, 26.4% prophylaxis, and 22.2% to suppress an infection. For 19.4% of prescriptions, participants or their family members specifically wanted to be treated with antibiotics. Only 9.7% of prescriptions specifically indicated that antibiotics were prescribed for palliative reasons.

Conclusion: Antibiotics were frequently prescribed for treatment of active infection in individuals discharged to hospice care. Further research is needed to document antibiotic benefits and risks and optimize medication management at the end of life.
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http://dx.doi.org/10.1111/jgs.15246DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5849491PMC
March 2018

Nosocomial Outbreak of Extensively Drug-Resistant Acinetobacter baumannii Isolates Containing Carried on a Plasmid.

Antimicrob Agents Chemother 2017 11 24;61(11). Epub 2017 Oct 24.

Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA

Carbapenem antibiotics are among the mainstays for treating infections caused by , especially in the Northwest United States, where carbapenem-resistant remains relatively rare. However, between June 2012 and October 2014, an outbreak of carbapenem-resistant occurred in 16 patients from five health care facilities in the state of Oregon. All isolates were defined as extensively drug resistant. Multilocus sequence typing revealed that the isolates belonged to sequence type 2 (international clone 2 [IC2]) and were >95% similar as determined by repetitive-sequence-based PCR analysis. Multiplex PCR revealed the presence of a carbapenemase gene, later identified as Whole-genome sequencing of all isolates revealed a well-supported separate branch within a global phylogeny. Pacific Biosciences (PacBio) SMRT sequencing was also performed on one isolate to gain insight into the genetic location of the carbapenem resistance gene. We discovered that , flanked on either side by IS elements in opposite orientations, was carried on a 15,198-bp plasmid designated pORAB01-3 and was present in all 16 isolates. The plasmid also contained genes encoding a TonB-dependent receptor, septicolysin, a type IV secretory pathway (VirD4 component, TraG/TraD family) ATPase, an integrase, a RepB family plasmid DNA replication initiator protein, an alpha/beta hydrolase, and a BrnT/BrnA type II toxin-antitoxin system. This is the first reported outbreak in the northwestern United States associated with this carbapenemase. Particularly worrisome is that was carried on a plasmid and found in the most prominent worldwide clonal group IC2, potentially giving pORAB01-3 great capacity for future widespread dissemination.
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http://dx.doi.org/10.1128/AAC.00797-17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5655091PMC
November 2017

Failure to Communicate: Transmission of Extensively Drug-Resistant bla OXA-237-Containing Acinetobacter baumannii-Multiple Facilities in Oregon, 2012-2014.

Infect Control Hosp Epidemiol 2017 11 5;38(11):1335-1341. Epub 2017 Sep 5.

1Public Health Division,Oregon Health Authority,Portland,Oregon.

OBJECTIVE To determine the scope, source, and mode of transmission of a multifacility outbreak of extensively drug-resistant (XDR) Acinetobacter baumannii. DESIGN Outbreak investigation. SETTING AND PARTICIPANTS Residents and patients in skilled nursing facilities, long-term acute-care hospital, and acute-care hospitals. METHODS A case was defined as the incident isolate from clinical or surveillance cultures of XDR Acinetobacter baumannii resistant to imipenem or meropenem and nonsusceptible to all but 1 or 2 antibiotic classes in a patient in an Oregon healthcare facility during January 2012-December 2014. We queried clinical laboratories, reviewed medical records, oversaw patient and environmental surveillance surveys at 2 facilities, and recommended interventions. Pulsed-field gel electrophoresis (PFGE) and molecular analysis were performed. RESULTS We identified 21 cases, highly related by PFGE or healthcare facility exposure. Overall, 17 patients (81%) were admitted to either long-term acute-care hospital A (n=8), or skilled nursing facility A (n=8), or both (n=1) prior to XDR A. baumannii isolation. Interfacility communication of patient or resident XDR status was not performed during transfer between facilities. The rare plasmid-encoded carbapenemase gene bla OXA-237 was present in 16 outbreak isolates. Contact precautions, chlorhexidine baths, enhanced environmental cleaning, and interfacility communication were implemented for cases to halt transmission. CONCLUSIONS Interfacility transmission of XDR A. baumannii carrying the rare blaOXA-237 was facilitated by transfer of affected patients without communication to receiving facilities. Infect Control Hosp Epidemiol 2017;38:1335-1341.
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http://dx.doi.org/10.1017/ice.2017.189DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5783543PMC
November 2017

Prevalence and Clinical Intentions of Antithrombotic Therapy on Discharge to Hospice Care.

J Palliat Med 2017 Nov 5;20(11):1225-1230. Epub 2017 Jun 5.

2 Department of Pharmacy Practice, Oregon State University/Oregon Health & Science University College of Pharmacy , Portland, Oregon.

Background: There are no guidelines for antithrombotic therapy on admission to hospice care. Antithrombotic therapy may offer some benefit in these patients, but is also associated with well-described risks.

Objective: We quantified the frequency and characteristics of patients prescribed antithrombotic therapy on discharge from acute care to hospice care.

Design: Retrospective cohort study. Settings/Subjects: Adult (age> = 21 years) patients discharged from acute care to hospice care between January 1, 2010 and June 30, 2014.

Measures: Our primary outcome of interest was receiving an outpatient prescription for antithrombotic therapy on discharge to hospice care.

Results: Among 1141 eligible patients, 77 (6.7%) patients received a prescription for antithrombotic therapy on discharge to hospice care, most frequently, aspirin (57.1%), enoxaparin (26.0%), and warfarin (20.8%). Patients actively treated for deep vein thromboembolism or pulmonary embolism, or with a history of atrial fibrillation or aortic/mitral valve replacement were significantly more likely to receive antithrombotic therapy. Patients with a history of cancer, cerebrovascular disease, or liver disease were significantly less likely to receive antithrombotic therapy (p < 0.05 for all). Among patients who received antithrombotic therapy, 22% were not receiving antithrombotic therapy before the index admission. Among patients previously receiving antithrombotic therapy, 55% continued on the same medication, of which 54.5% did not have any documented rationale for continuation.

Conclusions: Prescriptions for antithrombotic therapy were infrequent and often lacked a documented rationale. Further research is needed on the safety and effectiveness of antithrombotic therapy in hospice care and what drives current medication decisions in the absence of these data.
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http://dx.doi.org/10.1089/jpm.2016.0487DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5672614PMC
November 2017

Perceptions of Statin Discontinuation among Patients with Life-Limiting Illness.

J Palliat Med 2017 10 18;20(10):1098-1103. Epub 2017 May 18.

11 Department of Pharmacy Practice, Oregon State University/Oregon Health & Science University College of Pharmacy , Portland, Oregon.

Background: Optimal management of chronic medications for patients with life-limiting illness is uncertain. Medication deprescribing may improve outcomes in this population, but patient concerns regarding deprescribing are unclear.

Objective: The aim of this study was to quantify the perceived benefits and concerns of statin discontinuation among patients with life-limiting illness.

Design: Baseline data from a multicenter, pragmatic clinical trial of statin discontinuation were used.

Setting/subjects: Cognitively intact participants with a life expectancy of 1-12 months receiving statin medications for primary or secondary prevention were enrolled.

Measurements: Responses to a 9-item questionnaire addressing patient concerns about discontinuing statins were collected. We used Pearson chi-square tests to compare responses by primary life-limiting diagnosis (cancer, cardiovascular disease, other).

Results: Of 297 eligible participants, 58% had cancer, 8% had cardiovascular disease, and 30% other primary diagnoses. Mean (standard deviation) age was 72 (11) years. Fewer than 5% of participants expressed concern that statin deprescribing indicated physician abandonment. About one in five participants reported being told to take statins for the rest of their life (18%) or feeling that discontinuation represented prior wasted effort (18%). Many participants reported benefits of stopping statins, including spending less money on medications (63%), potentially stopping other medications (34%), and having a better quality of life (25%). More participants with cardiovascular disease as a primary diagnosis perceived that quality-of-life benefits related to statin discontinuation (52%) than participants with cancer (27%) or noncardiovascular disease diagnoses (27%) [p = 0.034].

Conclusion: Few participants expressed concerns about discontinuing statins; many perceived potential benefits. Cardiovascular disease patients perceived greater potential positive impact from statin discontinuation.
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http://dx.doi.org/10.1089/jpm.2016.0489DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5647503PMC
October 2017

Carbapenem MICs in Escherichia coli and Klebsiella Species Producing Extended-Spectrum β-Lactamases in Critical Care Patients from 2001 to 2009.

Antimicrob Agents Chemother 2017 04 24;61(4). Epub 2017 Mar 24.

Department of Pharmacy Practice, Oregon State University/Oregon Health & Science University College of Pharmacy, Portland, Oregon, USA.

Extended-spectrum β-lactamase (ESBL)-producing strains are increasing in prevalence worldwide. Carbapenem antibiotics are used as a first line of therapy against ESBL-producing We examined a cohort of critical care patients for gastrointestinal colonization with carbapenem-resistant ESBL-producing strains (CR-ESBL strains). We cultured samples from this cohort of patients for ESBL-producing spp. and and then tested the first isolate from each patient for susceptibility to imipenem, doripenem, meropenem, and ertapenem. Multilocus sequence typing was performed on isolates that produced an ESBL and that were carbapenem resistant. Among all patients admitted to an intensive care unit (ICU), 4% were positive for an ESBL-producing isolate and 0.64% were positive for a CR-ESBL strain on surveillance culture. Among the first ESBL-producing and isolates from the patients' surveillance cultures, 11.2% were carbapenem resistant. Sequence type 14 (ST14), ST15, ST42, and ST258 were the dominant sequence types detected in this cohort of patients, with ST15 and ST258 steadily increasing in prevalence from 2006 to 2009. Patients colonized by a CR-ESBL strain were significantly more likely to receive antipseudomonal and anti-methicillin-resistant (anti-MRSA) therapy prior to ICU admission than patients colonized by carbapenem-susceptible ESBL-producing strains. They were also significantly more likely to have received a cephalosporin or a carbapenem antibiotic than patients colonized by carbapenem-susceptible ESBL-producing strains. In conclusion, in a cohort of patients residing in intensive care units within the United States, we found that 10% of the isolates were resistant to at least one carbapenem antibiotic. The continued emergence of carbapenem-resistant ESBL-producing strains is of significant concern, as infections due to these organisms are notoriously difficult to treat.
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http://dx.doi.org/10.1128/AAC.01718-16DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5365708PMC
April 2017

Feasibility of Retrospective Pharmacovigilance Studies in Hospice Care: A Case Study of Antibiotics for the Treatment of Urinary Tract Infections.

J Palliat Med 2017 04 5;20(4):316-317. Epub 2017 Jan 5.

3 Palliative Care Service, Oregon Health & Science University Hospitals and Clinics , Portland, Oregon.

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http://dx.doi.org/10.1089/jpm.2016.0531DOI Listing
April 2017

Status of the Prevention of Multidrug-Resistant Organisms in International Settings: A Survey of the Society for Healthcare Epidemiology of America Research Network.

Infect Control Hosp Epidemiol 2017 01 7;38(1):53-60. Epub 2016 Nov 7.

17Division of Infectious Disease,Beth Israel Deaconess Medical Center,Boston,Massachusetts.

OBJECTIVE To examine self-reported practices and policies to reduce infection and transmission of multidrug-resistant organisms (MDRO) in healthcare settings outside the United States. DESIGN Cross-sectional survey. PARTICIPANTS International members of the Society for Healthcare Epidemiology of America (SHEA) Research Network. METHODS Electronic survey of infection control and prevention practices, capabilities, and barriers outside the United States and Canada. Participants were stratified according to their country's economic development status as defined by the World Bank as low-income, lower-middle-income, upper-middle-income, and high-income. RESULTS A total of 76 respondents (33%) of 229 SHEA members outside the United States and Canada completed the survey questionnaire, representing 30 countries. Forty (53%) were high-, 33 (43%) were middle-, and 1 (1%) was a low-income country. Country data were missing for 2 respondents (3%). Of the 76 respondents, 64 (84%) reported having a formal or informal antibiotic stewardship program at their institution. High-income countries were more likely than middle-income countries to have existing MDRO policies (39/64 [61%] vs 25/64 [39%], P=.003) and to place patients with MDRO in contact precautions (40/72 [56%] vs 31/72 [44%], P=.05). Major barriers to preventing MDRO transmission included constrained resources (infrastructure, supplies, and trained staff) and challenges in changing provider behavior. CONCLUSIONS In this survey, a substantial proportion of institutions reported encountering barriers to implementing key MDRO prevention strategies. Interventions to address capacity building internationally are urgently needed. Data on the infection prevention practices of low income countries are needed. Infect Control Hosp Epidemiol. 2016:1-8.
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http://dx.doi.org/10.1017/ice.2016.242DOI Listing
January 2017

Should we refrain from antibiotic use in hospice patients?

Expert Rev Anti Infect Ther 2016 6;14(3):277-80. Epub 2016 Jan 6.

b Division of Hematology and Medical Oncology, Knight Cancer Institute , Oregon Health & Science University , Portland , OR , USA.

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http://dx.doi.org/10.1586/14787210.2016.1128823DOI Listing
October 2016

Rural-Urban Differences in Chronic Disease and Drug Utilization in Older Oregonians.

J Rural Health 2016 06 30;32(3):269-79. Epub 2015 Oct 30.

Department of Pharmacy Practice, College of Pharmacy, Oregon State University/Oregon Health & Science University, Portland, Oregon.

Purpose: To characterize disease burden and medication usage in rural and urban adults aged ≥85 years.

Methods: This is a secondary analysis of 5 years of longitudinal data starting in the year 2000 from 3 brain-aging studies. Cohorts consisted of community-dwelling adults: 1 rural cohort, the Klamath Exceptional Aging Project (KEAP), was compared to 2 urban cohorts, the Oregon Brain Aging Study (OBAS) and the Dementia Prevention study (DPS). In this analysis, 121 participants were included from OBAS/DPS and 175 participants were included from KEAP. Eligibility was determined based on age ≥85 years and having at least 2 follow-up visits after the year 2000. Disease burden was measured by the Modified Cumulative Illness Rating Scale (MCIRS), with higher values representing more disease. Medication usage was measured by the estimated mean number of medications used by each cohort.

Findings: Rural participants had significantly higher disease burden as measured by MCIRS, 23.0 (95% CI: 22.3-23.6), than urban participants, 21.0 (95% CI: 20.2-21.7), at baseline. The rate of disease accumulation was a 0.2 increase in MCIRS per year (95% CI: 0.05-0.34) in the rural population. Rural participants used a higher mean number of medications, 5.5 (95% CI: 4.8-6.1), than urban participants, 3.7 (95% CI: 3.1-4.2), at baseline (P < .0001).

Conclusions: These data suggest that rural and urban Oregonians aged ≥85 years may differ by disease burden and medication usage. Future research should identify opportunities to improve health care for older adults.
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http://dx.doi.org/10.1111/jrh.12153DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5116378PMC
June 2016

Antibiotic Policies and Utilization in Oregon Hospice Programs.

Am J Hosp Palliat Care 2016 Sep 12;33(8):777-81. Epub 2015 Aug 12.

Department of Pharmacy Practice, Oregon State University/Oregon Health & Science University College of Pharmacy, Portland, OR, USA

Antibiotics are frequently used in hospice care, despite limited data on safety and effectiveness in this patient population. We surveyed Oregon hospice programs on antibiotic policies and prescribing practices. Among 39 responding hospice programs, the median reported proportion of current census using antibiotics was 10% (interquartile range = 3.5%-20.0%). Approximately 31% of responding hospice programs had policies for antibiotic initiation, 17% of hospice programs had policies for antibiotic discontinuation, and 95% of hospice programs had policies for managing drug interactions. Diarrhea, nausea/vomiting, and yeast infections were the most frequently reported antibiotic-associated adverse events, occurring "sometimes" or "often" among 62%, 47%, and 62% of respondents, respectively. In conclusion, less than a third of participating hospice programs reported having a policy for antibiotic initiation and even less frequently a policy for discontinuation. More data are needed on the risks and benefits of antibiotic use in hospice care to inform these policies and optimize outcomes in this vulnerable patient population.
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http://dx.doi.org/10.1177/1049909115599951DOI Listing
September 2016

Optimizing research methods used for the evaluation of antimicrobial stewardship programs.

Clin Infect Dis 2014 Oct;59 Suppl 3:S185-92

Department of Pharmacy Practice, Oregon State University/Oregon Health and Science University College of Pharmacy, Portland.

Antimicrobial stewardship programs (ASPs) are an increasingly common intervention for optimizing antimicrobial therapy in healthcare settings. These programs aim to improve patient care and limit the emergence and spread of multidrug-resistant organisms by supporting prudent antimicrobial use. However, pressure from the current reimbursement climate necessitates that ASPs operate as cost-cutting programs rather than focus on patient outcomes. This has forced the research that is evaluating ASP interventions to concentrate heavily on economic outcomes. As the science of antimicrobial stewardship advances, it is essential that well-conducted evaluations, focused on patient and microbial outcomes, serve as the evidence base that directs optimal ASP intervention design and implementation. In this review, we provide guidance and recommendations for the design of studies to evaluate the impact of ASP interventions on patient and microbial outcomes.
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http://dx.doi.org/10.1093/cid/ciu540DOI Listing
October 2014

Using antibiograms to improve antibiotic prescribing in skilled nursing facilities.

Infect Control Hosp Epidemiol 2014 Oct;35 Suppl 3:S56-61

Department of Pharmacy Practice, Oregon State University/Oregon Health and Science University College of Pharmacy, Portland, Oregon.

Background: Antibiograms have effectively improved antibiotic prescribing in acute-care settings; however, their effectiveness in skilled nursing facilities (SNFs) is currently unknown.

Objective: To develop SNF-specific antibiograms and identify opportunities to improve antibiotic prescribing.

Design And Setting: Cross-sectional and pretest-posttest study among residents of 3 Maryland SNFs.

Methods: Antibiograms were created using clinical culture data from a 6-month period in each SNF. We also used admission clinical culture data from the acute care facility primarily associated with each SNF for transferred residents. We manually collected all data from medical charts, and antibiograms were created using WHONET software. We then used a pretest-posttest study to evaluate the effectiveness of an antibiogram on changing antibiotic prescribing practices in a single SNF. Appropriate empirical antibiotic therapy was defined as an empirical antibiotic choice that sufficiently covered the infecting organism, considering antibiotic susceptibilities.

Results: We reviewed 839 patient charts from SNF and acute care facilities. During the initial assessment period, 85% of initial antibiotic use in the SNFs was empirical, and thus only 15% of initial antibiotics were based on culture results. Fluoroquinolones were the most frequently used empirical antibiotics, accounting for 54.5% of initial prescribing instances. Among patients with available culture data, only 35% of empirical antibiotic prescribing was determined to be appropriate. In the single SNF in which we evaluated antibiogram effectiveness, prevalence of appropriate antibiotic prescribing increased from 32% to 45% after antibiogram implementation; however, this was not statistically significant ([Formula: see text]).

Conclusions: Implementation of antibiograms may be effective in improving empirical antibiotic prescribing in SNFs.
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http://dx.doi.org/10.1086/677818DOI Listing
October 2014

Effectiveness of an antimicrobial polymer to decrease contamination of environmental surfaces in the clinical setting.

Infect Control Hosp Epidemiol 2014 Aug 20;35(8):1060-2. Epub 2014 Jun 20.

University of Maryland School of Medicine, Baltimore, Maryland.

We performed a real-world, controlled intervention to investigate use of an antimicrobial surface polymer, MSDS Poly, on environmental contamination. Pathogenic bacteria were identified in 18 (90%) of 20 observations in treated rooms and 19 (83%) of 23 observations in untreated rooms (P = .67). MSDS Poly had no significant effect on environmental contamination.
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http://dx.doi.org/10.1086/677159DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4294176PMC
August 2014

Frequency of outpatient antibiotic prescription on discharge to hospice care.

Antimicrob Agents Chemother 2014 Sep 7;58(9):5473-7. Epub 2014 Jul 7.

Palliative Care Service, Oregon Health & Science University, Portland, Oregon, USA Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon, USA.

The use of antibiotics is common in hospice care despite limited evidence that it improves symptoms or quality of life. Patients receiving antibiotics upon discharge from a hospital may be more likely to continue use following transition to hospice care despite a shift in the goals of care. We quantified the frequency and characteristics for receiving a prescription for antibiotics on discharge from acute care to hospice care. This was a cross-sectional study among adult inpatients (≥18 years old) discharged to hospice care from Oregon Health & Science University (OHSU) from 1 January 2010 to 31 December 2012. Data were collected from an electronic data repository and from the Department of Care Management. Among 62,792 discharges, 845 (1.3%) patients were discharged directly to hospice care (60.0% home and 40.0% inpatient). Most patients discharged to hospice were >65 years old (50.9%) and male (54.6%) and had stayed in the hospital for ≤7 days (56.6%). The prevalence of antibiotic prescription upon discharge to hospice was 21.1%. Among patients discharged with an antibiotic prescription, 70.8% had a documented infection during their index admission. Among documented infections, 40.3% were bloodstream infections, septicemia, or endocarditis, and 38.9% were pneumonia. Independent risk factors for receiving an antibiotic prescription were documented infection during the index admission (adjusted odds ratio [AOR]=7.00; 95% confidence interval [95% CI]=4.68 to 10.46), discharge to home hospice care (AOR=2.86; 95% CI=1.92 to 4.28), and having a cancer diagnosis (AOR=2.19; 95% CI=1.48 to 3.23). These data suggest that a high proportion of patients discharged from acute care to hospice care receive an antibiotic prescription upon discharge.
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http://dx.doi.org/10.1128/AAC.02873-14DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4135830PMC
September 2014

Establishment of a statewide network for carbapenem-resistant enterobacteriaceae prevention in a low-incidence region.

Infect Control Hosp Epidemiol 2014 Apr;35(4):356-61

Department of Hospital and Specialty Medicine, Portland Veterans Affairs Medical Center, Portland, Oregon.

Objective: To establish a statewide network to detect, control, and prevent the spread of carbapenem-resistant Enterobacteriaceae (CRE) in a region with a low incidence of CRE infection.

Design: Implementation of the Drug Resistant Organism Prevention and Coordinated Regional Epidemiology (DROP-CRE) Network.

Setting And Participants: Oregon infection prevention and microbiology laboratory personnel, including 48 microbiology laboratories, 62 acute care facilities, and 140 long-term care facilities.

Methods: The DROP-CRE working group, comprising representatives from academic institutions and public health, convened an interdisciplinary advisory committee to assist with planning and implementation of CRE epidemiology and control efforts. The working group established a statewide CRE definition and surveillance plan; increased the state laboratory capacity to perform the modified Hodge test and polymerase chain reaction for carbapenemases in real time; and administered surveys that assessed the needs and capabilities of Oregon infection prevention and laboratory personnel. Results of these inquiries informed CRE education and the response plan.

Results: Of 60 CRE reported from November 2010 through April 2013, only 3 were identified as carbapenemase producers; the cases were not linked, and no secondary transmission was found. Microbiology laboratories, acute care facilities, and long-term care facilities reported lacking carbapenemase testing capability, reliable interfacility communication, and CRE awareness, respectively. Survey findings informed the creation of the Oregon CRE Toolkit, a state-specific CRE guide booklet.

Conclusions: A regional epidemiology surveillance and response network has been implemented in Oregon in advance of widespread CRE transmission. Prospective surveillance will determine whether this collaborative approach will be successful at forestalling the emergence of this important healthcare-associated pathogen.
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http://dx.doi.org/10.1086/675605DOI Listing
April 2014
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