Publications by authors named "Marin L Schweizer"

112 Publications

Short-term effectiveness of COVID-19 vaccines in immunocompromised patients: A systematic literature review and meta-analysis.

J Infect 2022 Jan 1. Epub 2022 Jan 1.

Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA; Center for Access and Delivery Research and Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa, IA, USA.

Objectives: We aimed to assess the short-term effectiveness of COVID-19 vaccines among immunocompromised patients to prevent laboratory-confirmed symptomatic COVID-19 infection.

Methods: Systematic review and meta-analysis. We calculated the pooled diagnostic odds ratio [DOR] (95% CI) for COVID-19 infection between immunocompromised patients and healthy people or those with stable chronic medical conditions. VE was estimated as 100% x (1-DOR). We also investigated the rates of developing anti-SARS-CoV-2 spike protein IgG between the 2 groups.

Results: Twenty studies evaluating COVID-19 vaccine response, and four studies evaluating VE were included in the meta-analysis. The pooled DOR for symptomatic COVID-19 infection in immunocompromised patients was 0.296 (95% CI: 0.108-0.811) with an estimated VE of 70.4% (95% CI: 18.9%- 89.2%). When stratified by diagnosis, IgG antibody levels were much higher in the control group compared to immunocompromised patients with solid organ transplant (pOR 232.3; 95% Cl: 66.98-806.03), malignant diseases (pOR 42.0, 95% Cl: 11.68-151.03), and inflammatory rheumatic diseases (pOR 19.06; 95% Cl: 5.00-72.62).

Conclusions: We found COVID-19 mRNA vaccines were effective against symptomatic COVID-19 among the immunocompromised patients but had lower VE compared to the controls. Further research is needed to understand the discordance between antibody production and protection against symptomatic COVID-19 infection.
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http://dx.doi.org/10.1016/j.jinf.2021.12.035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8720049PMC
January 2022

Using nasal povidone-iodine to prevent bloodstream infections and transmission of among haemodialysis patients: a stepped-wedge cluster randomised control trial protocol.

BMJ Open 2021 Dec 3;11(12):e048830. Epub 2021 Dec 3.

Internal Medicine, The University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA.

Introduction: Approximately 38% of haemodialysis patients carry in their noses, and carriers have a nearly four-fold increased risk of access-related bloodstream infections (BSIs) compared with non-carriers. Our objective is to determine the clinical efficacy and effectiveness of a novel intervention using nasal povidone-iodine (PVI) to prevent BSIs among patients in haemodialysis units. We will survey patients and conduct qualitative interviews with healthcare workers to identify barriers and facilitators to implementing the intervention.

Methods And Analysis: We will perform an open-label, stepped-wedge cluster randomised trial to assess the effectiveness of nasal PVI compared with standard care. Sixteen outpatient haemodialysis units will participate in the study. The 3-year trial period will be divided into a 4-month baseline period and eight additional 4-month time blocks. The primary outcome of the study will be BSI, defined as a positive blood culture collected in the outpatient setting or within one calendar day after a hospital admission. The study team will evaluate characteristics of individual patients and the clusters by exposure status (control or intervention) to assess the balance between groups, and calculate descriptive statistics such as average responses separately for control and intervention survey questions.

Ethics And Dissemination: This study has received IRB approval from all study sites. A Data Safety and Monitoring Board will monitor this multicentre clinical trial. We will present our results at international meetings. The study team will publish findings in peer-reviewed journals and make each accepted peer-reviewed manuscript publicly available.

Trial Registration Number: NCT04210505.
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http://dx.doi.org/10.1136/bmjopen-2021-048830DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8647395PMC
December 2021

Self-controlled assessment of thromboembolic event (TEE) risk following intravenous immune globulin (IGIV) in the U.S. (2006-2012).

J Thromb Thrombolysis 2021 Nov 24. Epub 2021 Nov 24.

Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA.

Since 2013, the U.S. Food and Drug administration (FDA) has required that intravenous immune globulin (IGIV) products carry a boxed warning concerning the risk of thromboembolic events (TEEs). This study assessed the incidence of TEEs attributable to IGIV in a large population-based cohort. A self-controlled risk interval design was used to quantify the transient increase in TEE risk during the risk interval (days 0-2 and 0-13 following IGIV for arterial and venous TEEs, respectively) relative to a later control interval (days 14-27 following IGIV). Potential IGIV-exposed TEE cases from 2006 to 2012 were identified from the FDA-sponsored Sentinel Distributed Database and confirmed through medical record review. Inpatient IGIV exposures were not included in the venous TEE analysis due to concerns about time-varying confounding. 19,069 new users of IGIV who received 93,555 treatment episodes were included. Charts were retrieved for 62% and 70% of potential venous and arterial cases, respectively. There was a transient increase in the risk of arterial TEEs during days 0-2 following IGIV treatment (RR = 4.69; 95% CI 1.87, 11.90; absolute increase in risk = 8.86 events per 10,000 patients, 95% CI 3.25, 14.6), but no significant increase in venous TEE risk during days 0-13 following outpatient IGIV treatments (RR = 1.07, 95% CI 0.34, 3.48). Our results suggest there is a small increase in the absolute risk of arterial TEEs following IGIV. However, lower-than-expected chart retrieval rates and the possibility of time-varying confounding mean that our results should be interpreted cautiously. Continued pharmacovigilance efforts are warranted.
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http://dx.doi.org/10.1007/s11239-021-02610-4DOI Listing
November 2021

The impact of workload on hand hygiene compliance: Is 100% compliance achievable?

Infect Control Hosp Epidemiol 2021 May 14:1-3. Epub 2021 May 14.

Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa.

Hand hygiene compliance decreased significantly when opportunities exceeded 30 per hour. At higher workloads, the number of healthcare worker types involved and the proportion of hand hygiene opportunities for which physicians and other healthcare workers were responsible increased. Thus, care complexity and risk to patients may both increase with workload.
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http://dx.doi.org/10.1017/ice.2021.179DOI Listing
May 2021

Hand hygiene and the sequence of patient care.

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

Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa.

Objective: To determine whether the order in which healthcare workers perform patient care tasks affects hand hygiene compliance.

Design: For this retrospective analysis of data collected during the Strategies to Reduce Transmission of Antimicrobial Resistant Bacteria in Intensive Care Units (STAR*ICU) study, we linked consecutive tasks healthcare workers performed into care sequences and identified task transitions: 2 consecutive task sequences and the intervening hand hygiene opportunity. We compared hand hygiene compliance rates and used multiple logistic regression to determine the adjusted odds for healthcare workers (HCWs) transitioning in a direction that increased or decreased the risk to patients if healthcare workers did not perform hand hygiene before the task and for HCWs contaminating their hands.

Setting: The study was conducted in 17 adult surgical, medical, and medical-surgical intensive care units.

Participants: HCWs in the STAR*ICU study units.

Results: HCWs moved from cleaner to dirtier tasks during 5,303 transitions (34.7%) and from dirtier to cleaner tasks during 10,000 transitions (65.4%). Physicians (odds ratio [OR]: 1.50; P < .0001) and other HCWs (OR, 2.15; P < .0001) were more likely than nurses to move from dirtier to cleaner tasks. Glove use was associated with moving from dirtier to cleaner tasks (OR, 1.22; P < .0001). Hand hygiene compliance was lower when HCWs transitioned from dirtier to cleaner tasks than when they transitioned in the opposite direction (adjusted OR, 0.93; P < .0001).

Conclusions: HCWs did not organize patient care tasks in a manner that decreased risk to patients, and they were less likely to perform hand hygiene when transitioning from dirtier to cleaner tasks than the reverse. These practices could increase the risk of transmission or infection.
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http://dx.doi.org/10.1017/ice.2021.82DOI Listing
April 2021

Reply to Authors.

Clin Infect Dis 2021 09;73(6):1129-1130

Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs (VA) Health Care System, Iowa City, Iowa USA.

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http://dx.doi.org/10.1093/cid/ciab249DOI Listing
September 2021

Development of a fully automated surgical site infection detection algorithm for use in cardiac and orthopedic surgery research.

Infect Control Hosp Epidemiol 2021 10 23;42(10):1215-1220. Epub 2021 Feb 23.

Center for Access & Delivery Research & Evaluation (CADRE), Iowa City Veterans' Affairs Health Care System, Iowa City, Iowa.

Objective: To develop a fully automated algorithm using data from the Veterans' Affairs (VA) electrical medical record (EMR) to identify deep-incisional surgical site infections (SSIs) after cardiac surgeries and total joint arthroplasties (TJAs) to be used for research studies.

Design: Retrospective cohort study.

Setting: This study was conducted in 11 VA hospitals.

Participants: Patients who underwent coronary artery bypass grafting or valve replacement between January 1, 2010, and March 31, 2018 (cardiac cohort) and patients who underwent total hip arthroplasty or total knee arthroplasty between January 1, 2007, and March 31, 2018 (TJA cohort).

Methods: Relevant clinical information and administrative code data were extracted from the EMR. The outcomes of interest were mediastinitis, endocarditis, or deep-incisional or organ-space SSI within 30 days after surgery. Multiple logistic regression analysis with a repeated regular bootstrap procedure was used to select variables and to assign points in the models. Sensitivities, specificities, positive predictive values (PPVs) and negative predictive values were calculated with comparison to outcomes collected by the Veterans' Affairs Surgical Quality Improvement Program (VASQIP).

Results: Overall, 49 (0.5%) of the 13,341 cardiac surgeries were classified as mediastinitis or endocarditis, and 83 (0.6%) of the 12,992 TJAs were classified as deep-incisional or organ-space SSIs. With at least 60% sensitivity, the PPVs of the SSI detection algorithms after cardiac surgeries and TJAs were 52.5% and 62.0%, respectively.

Conclusions: Considering the low prevalence rate of SSIs, our algorithms were successful in identifying a majority of patients with a true SSI while simultaneously reducing false-positive cases. As a next step, validation of these algorithms in different hospital systems with EMR will be needed.
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http://dx.doi.org/10.1017/ice.2020.1387DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8506349PMC
October 2021

Meta-analysis of Clinical Outcomes Using Ceftazidime/Avibactam, Ceftolozane/Tazobactam, and Meropenem/Vaborbactam for the Treatment of Multidrug-Resistant Gram-Negative Infections.

Open Forum Infect Dis 2021 Feb 5;8(2):ofaa651. Epub 2021 Jan 5.

Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines Jr. Veterans Affairs Hospital, Hines, Illinois, USA.

Ceftolozane-tazobactam (C/T), ceftazidime-avibactam (C/A), and meropenem/vaborbactam (M/V) are new beta-lactam/beta-lactamase combination antibiotics commonly used to treat multidrug-resistant (MDRPA) and carbapenem-resistant (CRE) infections. This review reports the clinical success rates for C/T, C/A, and M/V. PubMed and EMBASE were searched from January 1, 2012, through September 2, 2020, for publications detailing the use of C/T, C/A, and M/V. A meta-analysis determined the pooled effectiveness of C/T, C/A, and M/V. The literature search returned 1950 publications; 29 publications representing 1620 patients were retained. Pneumonia was the predominant infection type (49.8%). MDRPA was the major pathogen treated (65.3%). The pooled clinical success rate was 73.3% (95% CI, 68.9%-77.5%). C/T, C/A, or M/V resistance was reported in 8.9% of the population. These antibiotics had a high clinical success rate in patients with complicated infections and limited treatment options. Larger studies comparing C/T, C/A, and M/V against other antibiotic regimens are needed.
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http://dx.doi.org/10.1093/ofid/ofaa651DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7875326PMC
February 2021

Expanding an Economic Evaluation of the Veterans Affairs (VA) Methicillin-resistant Staphylococcus aureus (MRSA) Prevention Initiative to Include Prevention of Infections From Other Pathogens.

Clin Infect Dis 2021 01;72(Suppl 1):S50-S58

Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah, USA.

Background: In October 2007, Veterans Affairs (VA) launched a nationwide effort to reduce methicillin-resistant Staphylococcus aureus (MRSA) transmission called the National MRSA Prevention Initiative. Although the initiative focused on MRSA, recent evidence suggests that it also led to a significant decrease in hospital-onset (HO) gram-negative rod (GNR) bacteremia, vancomycin-resistant Enterococci (VRE), and Clostridioides difficile infections. The objective of this analysis was to evaluate the cost-effectiveness and the budget impact of the initiative taking into account MRSA, GNR, VRE, and C. difficile infections.

Methods: We developed an economic model using published data on the rate of MRSA hospital-acquired infections (HAIs) and HO-GNR bacteremia in the VA from October 2007 to September 2015, estimates of the attributable cost and mortality of these infections, and the costs associated with the intervention obtained through a microcosting approach. We explored several different assumptions for the rate of infections that would have occurred if the initiative had not been implemented. Effectiveness was measured in life-years (LYs) gained.

Results: We found that during fiscal years 2008-2015, the initiative resulted in an estimated 4761-9236 fewer MRSA HAIs, 1447-2159 fewer HO-GNR bacteremia, 3083-3602 fewer C. difficile infections, and 2075-5393 fewer VRE infections. The initiative itself was estimated to cost $561 million over this 8-year period, whereas the cost savings from prevented MRSA HAIs ranged from $165 to $315 million and from prevented HO-GNR bacteremia, CRE and C. difficile infections ranged from $174 to $200 million. The incremental cost-effectiveness of the initiative ranged from $12 146 to $38 673/LY when just including MRSA HAIs and from $1354 to $4369/LY when including the additional pathogens. The overall impact on the VA's budget ranged from $67 to$195 million.

Conclusions: An MRSA surveillance and prevention strategy in VA may have prevented a substantial number of infections from MRSA and other organisms. The net increase in cost from implementing this strategy was quite small when considering infections from all types of organisms. Including spillover effects of organism-specific prevention efforts onto other organisms can provide a more comprehensive evaluation of the costs and benefits of these interventions.
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http://dx.doi.org/10.1093/cid/ciaa1591DOI Listing
January 2021

Comparative Effectiveness of Switching to Daptomycin Versus Remaining on Vancomycin Among Patients With Methicillin-resistant Staphylococcus aureus (MRSA) Bloodstream Infections.

Clin Infect Dis 2021 01;72(Suppl 1):S68-S73

Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa USA.

Background: Patients with methicillin-resistant Staphylococcus aureus bloodstream infections (MRSA BSI) usually receive initial treatment with vancomycin but may be switched to daptomycin for definitive therapy, especially if treatment failure is suspected. Our objective was to evaluate the effectiveness of switching from vancomycin to daptomycin compared with remaining on vancomycin among patients with MRSA BSI.

Methods: Patients admitted to 124 Veterans Affairs Hospitals who experienced MRSA BSI and were treated with vancomycin during 2007-2014 were included. The association between switching to daptomycin and 30-day mortality was assessed using Cox regression models. Separate models were created for switching to daptomycin any time during the first hospitalization and for switching within 3 days of receiving vancomycin.

Results: In total, 7411 patients received vancomycin for MRSA BSI. Also, 606 (8.2%) patients switched from vancomycin to daptomycin during the first hospitalization, and 108 (1.5%) switched from vancomycin to daptomycin within 3 days of starting vancomycin. In the multivariable analysis, switching to daptomycin within 3 days was significantly associated with lower 30-day mortality (hazards ratio [HR] = 0.48; 95% confidence interval [CI]: .25, .92). However, switching to daptomycin at any time during the first hospitalization was not significantly associated with 30-day mortality (HR: 0.87; 95% CI: .69, 1.09).

Conclusions: Switching to daptomycin within 3 days of initial receipt of vancomycin is associated with lower 30-day mortality among patients with MRSA BSI. This benefit was not seen when the switch occurred later. Future studies should prospectively assess the benefit of early switching from vancomycin to other anti-MRSA antibiotics.
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http://dx.doi.org/10.1093/cid/ciaa1572DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7850170PMC
January 2021

Positive deviance in infection prevention and control: A systematic literature review.

Infect Control Hosp Epidemiol 2020 Nov 11:1-8. Epub 2020 Nov 11.

University of Iowa Carver College of Medicine, Iowa City, Iowa, United States.

Background: Healthcare-associated infections (HAIs) remain a major challenge. Various strategies have been tried to prevent or control HAIs. Positive deviance, a strategy that has been used in the last decade, is based on the observation that a few at-risk individuals follow uncommon, useful practices and that, consequently, they experience better outcomes than their peers who share similar risks. We performed a systematic literature review to measure the impact of positive deviance in controlling HAIs.

Methods: A systematic search strategy was used to search PubMed, CINAHL, Scopus, and Embase through May 2020 for studies evaluating positive deviance as a single intervention or as part of an initiative to prevent or control healthcare-associated infections. The risk of bias was evaluated using the Downs and Black score.

Results: Of 542 articles potentially eligible for review, 14 articles were included for further analysis. All studies were observational, quasi-experimental (before-and-after intervention) studies. Hand hygiene was the outcome in 8 studies (57%), and an improvement was observed in association with implementation of positive deviance as a single intervention in all of them. Overall HAI rates were measured in 5 studies (36%), and positive deviance was associated with an observed reduction in 4 (80%) of them. Methicillin-resistant Staphylococcus aureus infections were evaluated in 5 studies (36%), and positive deviance containing bundles were successful in all of them.

Conclusions: Positive deviance may be an effective strategy to improve hand hygiene and control HAIs. Further studies are needed to confirm this effect.
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http://dx.doi.org/10.1017/ice.2020.1256DOI Listing
November 2020

Meta-Analysis of VTE Risk: Ovarian Cancer Patients by Stage, Histology, Cytoreduction, and Ascites at Diagnosis.

Obstet Gynecol Int 2020 3;2020:2374716. Epub 2020 Sep 3.

Carver College of Medicine, University of Iowa, Iowa City 52242, IA, USA.

Venous thromboembolisms (VTEs) have been a leading secondary cause of death among ovarian cancer patients, prompting multiple studies of risk factors. The objective of this meta-analysis is to quantify the associations between VTE and the most commonly reported risk factors among ovarian cancer patients. PubMed, Embase, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) were used to identify observational studies. Two reviewers independently abstracted data and assessed quality via the Newcastle-Ottawa tool. A random effects model was used to calculate the pooled odds ratios for VTE with each of the following exposures: advanced cancer stage, clear cell histology, serous histology, ascites at diagnosis, and complete cytoreduction. The and tests were used to evaluate heterogeneity. Twenty cohort studies with 6,324 total ovarian cancer patients, 769 of whom experienced a VTE, were included. The odds of VTE in ovarian cancer patients were higher among patients with cancer stage III/IV (versus cancer stage I/II, pooled odds ratio (OR) 2.73; 95% CI 1.84-4.06; = 64%), clear cell (versus nonclear cell) histology (OR 2.11; 95% CI 1.55-2.89;  = 6%), and ascites (versus no ascites) at diagnosis (OR 2.12; 95% CI 1.51-2.96;  = 32%). Serous (versus nonserous) histology (OR 1.26; 95% CI 0.91-1.75;  = 42%) and complete (versus incomplete) cytoreduction (OR 1.05; 95% CI 0.27-4.11;  = 88%) were not associated with VTE. This meta-analysis quantifies the significantly elevated odds of VTE in ovarian cancer patients with advanced stage at diagnosis, clear cell histology, and ascites at diagnosis. Further studies are needed to account for confounders and inform clinical decision-making tools.
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http://dx.doi.org/10.1155/2020/2374716DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7486642PMC
September 2020

Novel Method to Flag Cardiac Implantable Device Infections by Integrating Text Mining With Structured Data in the Veterans Health Administration's Electronic Medical Record.

JAMA Netw Open 2020 09 1;3(9):e2012264. Epub 2020 Sep 1.

Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts.

Importance: Health care-associated infections (HAIs) are preventable, harmful, and costly; however, few resources are dedicated to infection surveillance of nonsurgical procedures, particularly cardiovascular implantable electronic device (CIED) procedures.

Objective: To develop a method that includes text mining of electronic clinical notes to reliably and efficiently measure HAIs for CIED procedures.

Design, Setting, And Participants: In this multicenter, national cohort study using electronic medical record data for patients undergoing CIED procedures in Veterans Health Administration (VA) facilities for fiscal years (FYs) 2016 and 2017, an algorithm to flag cases with a true CIED-related infection based on structured (eg, microbiology orders, vital signs) and free text diagnostic and therapeutic data (eg, procedure notes, discharge summaries, microbiology results) was developed and validated. Procedure data were divided into development and validation data sets. Criterion validity (ie, positive predictive validity [PPV], sensitivity, and specificity) was assessed via criterion-standard manual medical record review.

Exposures: CIED procedure.

Main Outcomes And Measures: The concordance between medical record review and the study algorithm with respect to the presence or absence of a CIED infection. CIED infection in the algorithm included 90-day mortality, congestive heart failure and nonmetastatic tumor comorbidities, CIED or surgical site infection International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes, antibiotic treatment of Staphylococci, a microbiology test of a cardiac specimen, and text documentation of infection in specific clinical notes (eg, cardiology, infectious diseases, inpatient discharge summaries).

Results: The algorithm sample consisted of 19 212 CIED procedures; 15 077 patients (78.5%) were White individuals, 1487 (15.5%) were African American; 18 766 (97.7%) were men. The mean (SD) age in our sample was 71.8 (10.6) years. The infection detection threshold of predicted probability was set to greater than 0.10 and the algorithm flagged 276 of 9606 (2.9%) cases in the development data set (9606 procedures); PPV in this group was 41.4% (95% CI, 31.6%-51.8%). In the validation set (9606 procedures), at predicted probability 0.10 or more the algorithm PPV was 43.5% (95% CI, 37.1%-50.2%), and overall sensitivity and specificity were 94.4% (95% CI, 88.2%-97.9%) and 48.8% (95% CI, 42.6%-55.1%), respectively.

Conclusions And Relevance: The findings of this study suggest that the method of combining structured and text data in VA electronic medical records can be used to expand infection surveillance beyond traditional boundaries to include outpatient and procedural areas.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.12264DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7506515PMC
September 2020

Disparities in breast cancer stage at diagnosis between immigrant and native-born women: A meta-analysis.

Ann Epidemiol 2021 02 18;54:64-72.e7. Epub 2020 Sep 18.

Department of Epidemiology, College of Public Health, University of Iowa, Iowa City; Center for Access & Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, IA.

Purpose: To synthesize existing observational evidence to identify disparities in stage at breast cancer diagnosis between foreign- and native-born women. We hypothesized immigrant women would be less likely than natives to be diagnosed at a localized stage.

Methods: Systematic searches for studies detailing stage at breast cancer diagnosis by birthplace in PubMed, Embase, and Web of Science yielded 11 relevant cohort studies from six countries. Odds ratios were pooled using random effects models.

Results: Foreign-born women were 12% less likely to be diagnosed with breast cancer at a localized stage than natives (OR 0.88, 95% CI 0.82-0.95). A similar disadvantage was observed in immigrants from Asia, Eastern Europe, Latin America and the Caribbean, and developing or in transition nations; immigrants from developed countries experienced the least disparity.

Conclusions: This meta-analysis confirmed the presence of significant differences in breast cancer stage at diagnosis as per nativity. Across diverse immigrant groups and host countries, foreign-born women were significantly less likely to be diagnosed with localized breast cancer than native women; the magnitude of the disparity varied by region and economic condition of immigrants' birthplace.
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http://dx.doi.org/10.1016/j.annepidem.2020.09.005DOI Listing
February 2021

Effectiveness of chlorhexidine dressings to prevent catheter-related bloodstream infections. Does one size fit all? A systematic literature review and meta-analysis.

Infect Control Hosp Epidemiol 2020 12 16;41(12):1388-1395. Epub 2020 Sep 16.

University of Iowa Carver College of Medicine, Iowa City, Iowa, United States.

Objective: To evaluate the effectiveness of chlorhexidine (CHG) dressings to prevent catheter-related bloodstream infections (CRBSIs).

Design: Systematic review and meta-analysis.

Methods: We searched PubMed, CINAHL, EMBASE, and ClinicalTrials.gov for studies (randomized controlled and quasi-experimental trials) with the following criteria: patients with short- or long-term catheters; CHG dressings were used in the intervention group and nonantimicrobial dressings in the control group; CRBSI was an outcome. Random-effects models were used to obtain pooled risk ratios (pRRs). Heterogeneity was evaluated using the I2 test and the Cochran Q statistic.

Results: In total, 20 studies (18 randomized controlled trials; 15,590 catheters) without evidence of publication bias and mainly performed in intensive care units (ICUs) were included. CHG dressings significantly reduced CRBSIs (pRR, 0.71; 95% CI, 0.58-0.87), independent of the CHG dressing type used. Benefits were limited to adults with short-term central venous catheters (CVCs), including onco-hematological patients. For long-term CVCs, CHG dressings decreased exit-site/tunnel infections (pRR, 0.37; 95% CI, 0.22-0.64). Contact dermatitis was associated with CHG dressing use (pRR, 5.16; 95% CI, 2.09-12.70); especially in neonates and pediatric populations in whom severe reactions occurred. Also, 2 studies evaluated and did not find CHG-acquired resistance.

Conclusions: CHG dressings prevent CRBSIs in adults with short-term CVCs, including patients with an onco-hematological disease. CHG dressings might reduce exit-site and tunnel infections in long-term CVCs. In neonates and pediatric populations, proof of CHG dressing effectiveness is lacking and there is an increased risk of serious adverse events. Future studies should investigate CHG effectiveness in non-ICU settings and monitor for CHG resistance.
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http://dx.doi.org/10.1017/ice.2020.356DOI Listing
December 2020

Impact of Infectious Disease Consultation in Patients With Candidemia: A Retrospective Study, Systematic Literature Review, and Meta-analysis.

Open Forum Infect Dis 2020 Sep 3;7(9):ofaa270. Epub 2020 Aug 3.

Division of Infectious Diseases, Department of Internal Medicine, University of Iowa, Iowa City, Iowa, USA.

Background: Morbidity and mortality from candidemia remain unacceptably high. While infectious disease consultation (IDC) is known to lower the mortality from bacteremia, little is known about the impact of IDC in candidemia.

Methods: We conducted a retrospective observational cohort study of candidemia patients at a large tertiary care hospital between 2015 and 2019. The crude mortality rate was compared between those with IDC and without IDC. Then, we systematically searched 5 databases through February 2020 and performed a meta-analysis of the impact of IDC on the mortality of patients with candidemia.

Results: A total of 151 patients met the inclusion criteria, 129 (85%) of whom received IDC. Thirty-day and 90-day mortality rates were significantly lower in the IDC group (18% vs 50%; = .002; 23% vs 50%; = .0022, respectively). A systematic literature review returned 216 reports, of which 13 studies including the present report fulfilled the inclusion criteria. Among the 13 studies with a total of 3582 patients, IDC was performed in 50% of patients. Overall mortality was 38.2% with a significant difference in favor of the IDC group (28.4% vs 47.6%), with a pooled relative risk of 0.41 (95% CI, 0.35-0.49). Ophthalmology referral, echocardiogram, and central line removal were performed more frequently among patients receiving IDC.

Conclusions: This study is the first systematic literature review and meta-analysis to evaluate the association between IDC and candidemia mortality. IDC was associated with significantly lower mortality and should be considered in all patients with candidemia.
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http://dx.doi.org/10.1093/ofid/ofaa270DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7462368PMC
September 2020

Development and Validation of a Semi-Automated Surveillance Algorithm for Cardiac Device Infections: Insights from the VA CART program.

Sci Rep 2020 03 24;10(1):5276. Epub 2020 Mar 24.

Department of Medicine, Division of Infectious Diseases, Boston VA Healthcare System, West Roxbury, Massachusetts, USA.

Procedure-related cardiac electronic implantable device (CIED) infections have high morbidity and mortality, highlighting the urgent need for infection prevention efforts to include electrophysiology procedures. We developed and validated a semi-automated algorithm based on structured electronic health records data to reliably identify CIED infections. A sample of CIED procedures entered into the Veterans' Health Administration Clinical Assessment Reporting and Tracking program from FY 2008-2015 was reviewed for the presence of CIED infection. This sample was then randomly divided into training (2/3) validation sets (1/3). The training set was used to develop a detection algorithm containing structured variables mapped from the clinical pathways of CIED infection. Performance of this algorithm was evaluated using the validation set. 2,107 unique CIED procedures from a cohort of 5,753 underwent manual review; 97 CIED infections (4.6%) were identified. Variables strongly associated with true infections included presence of a microbiology order, billing codes for surgical site infections and post-procedural antibiotic prescriptions. The combined algorithm to detect infection demonstrated high c-statistic (0.95; 95% confidence interval: 0.92-0.98), sensitivity (87.9%) and specificity (90.3%) in the validation data. Structured variables derived from clinical pathways can guide development of a semi-automated detection tool to surveil for CIED infection.
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http://dx.doi.org/10.1038/s41598-020-62083-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7093485PMC
March 2020

A randomized control trial evaluating efficacy of antimicrobial impregnated hospital privacy curtains in an intensive care setting.

Am J Infect Control 2020 08 3;48(8):862-868. Epub 2020 Mar 3.

Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA; Center for Emerging Infectious Diseases, University of Iowa Research Park, Coralville, IA.

Background: Acquisition of pathogens into health care settings from prior room occupants has been documented. Hospital room privacy curtains are at high risk for pathogenic bacterial contamination. Antimicrobial impregnated curtains could be effective in reducing contamination.

Methods: Rooms within an intensive care unit at The University of Iowa Hospitals and Clinics were randomized to 3 arms. The 2 intervention arms: (1) halamine antimicrobial curtains (BioSmart curtain [BSC]) and (2) halamine antimicrobial curtains sprayed twice weekly with a sodium hypochlorite-based disinfecting spray (BSC-pre and BSC-post) and a third control arm (standard curtain [SC]). Samples were collected twice weekly for 3 weeks to assess pathogenic bacterial contamination.

Results: The likelihood of remaining uncontaminated was 38% for SC, 37% for BSC, and 60% for the BSC-pre group. Time to event (contamination) analysis found no statistically significant difference between pathogenic contamination between the SC, BSC, and BSC-pre groups (P value = .1921). There was a decrease in average colony count for BSC curtains compared with control, however, this difference was not statistically significant. Hypochlorite spray was found to transiently decontaminate curtains, but effects dissipated after 72 hours.

Conclusions: BSC did not show a significant reduction in pathogenic contamination compared with control. Antimicrobial curtains could have a role in reducing environmental contamination in the health care setting. Future studies should be done to determine the long-term effects of using antimicrobial curtains in health care.
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http://dx.doi.org/10.1016/j.ajic.2019.12.024DOI Listing
August 2020

Association of Infectious Diseases Consultation With Long-term Postdischarge Outcomes Among Patients With Staphylococcus aureus Bacteremia.

JAMA Netw Open 2020 02 5;3(2):e1921048. Epub 2020 Feb 5.

Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa.

Importance: Staphylococcus aureus bacteremia (SAB) is common and associated with poor long-term outcomes. Previous studies have demonstrated an association between infectious diseases (ID) consultation and improved short-term (ie, within 90 days) outcomes for patients with SAB, but associations with long-term outcomes are unknown.

Objective: To investigate the association of ID consultation with long-term (ie, 5 years) postdischarge outcomes among patients with SAB.

Design, Setting, And Participants: This cohort study included all patients (N = 31 002) with a first episode of SAB who were discharged alive from 116 acute care units of the nationwide Veterans Health Administration where ID consultation was offered. Data were collected from January 2003 to December 2014, with follow-up through September 30, 2018. Data analysis was conducted from February to December 2019.

Exposures: Infectious diseases consultation during the index hospital stay.

Main Outcomes And Measures: The primary outcome was time to development of a composite event of all-cause mortality or recurrence of SAB within 5 years of discharge. As secondary outcomes, SAB recurrence and all-cause mortality with and without recurrence were analyzed while accounting for semicompeting risks.

Results: The cohort included 31 002 patients (30 265 [97.6%] men; median [interquartile range] age at SAB onset, 64.0 [57.0-75.0] years). Among 31 002 patients, there were 18 794 (60.6%) deaths, 4772 (15.4%) SAB recurrences, and 20 414 (65.8%) composite events during 5 years of follow-up; 12 773 deaths (68.0%) and 2268 recurrences (47.5%) occurred more than 90 days after discharge. Approximately half of patients (15 360 [49.5%]) received ID consultation during the index hospital stay; ID consultation was associated with prolonged improvement in the composite outcome (adjusted hazard ratio at 5 years, 0.71; 95% CI, 0.68-0.74; P < .001). Infectious diseases consultation was also associated with improved outcomes when all-cause mortality without recurrence and SAB recurrence were analyzed separately (all-cause mortality without recurrence: adjusted hazard ratio at 5 years, 0.77; 95% CI, 0.74-0.81; P < .001; SAB recurrence: adjusted hazard ratio at 5 years, 0.68; 95% CI, 0.64-0.72; P < .001).

Conclusions And Relevance: Having an ID consultation during the index hospital stay among patients with SAB was associated with improved postdischarge outcomes for at least 5 years, suggesting that contributions of ID specialists to management during acute infection may have a substantial influence on long-term outcomes. Further investigations of the association of ID consultation with outcomes after S aureus should include long-term follow-up.
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http://dx.doi.org/10.1001/jamanetworkopen.2019.21048DOI Listing
February 2020

Hand Hygiene Compliance at Critical Points of Care.

Clin Infect Dis 2021 03;72(5):814-820

Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA.

Background: Most articles on hand hygiene report either overall compliance or compliance with specific hand hygiene moments. These moments vary in the level of risk to patients if healthcare workers (HCWs) are noncompliant. We assessed how task type affected HCWs' hand hygiene compliance.

Methods: We linked consecutive tasks individual HCWs performed during the Strategies to Reduce Transmission of Antimicrobial Resistant Bacteria in Intensive Care Units (STAR*ICU) study into care sequences and identified task pairs-2 consecutive tasks and the intervening hand hygiene opportunity. We defined tasks as critical and/or contaminating. We determined the odds of critical and contaminating tasks occurring, and the odds of hand hygiene compliance using logistic regression for transition with a random effect adjusting for isolation precautions, glove use, HCW type, and compliance at prior opportunities.

Results: Healthcare workers were less likely to do hand hygiene before critical tasks than before other tasks (adjusted odds ratio [aOR], 0.97 [95% confidence interval {CI}, .95-.98]) and more likely to do hand hygiene after contaminating tasks than after other tasks (aOR, 1.12 [95% CI, 1.10-1.13]). Nurses were more likely to perform both critical and contaminating tasks, but nurses' hand hygiene compliance was better than physicians' (aOR, 0.94 [95% CI, .91-.97]) and other HCWs' compliance (aOR, 0.87 [95% CI, .87-.94]).

Conclusions: Healthcare workers were more likely to do hand hygiene after contaminating tasks than before critical tasks, suggesting that habits and a feeling of disgust may influence hand hygiene compliance. This information could be incorporated into interventions to improve hand hygiene practices, particularly before critical tasks and after contaminating tasks.
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http://dx.doi.org/10.1093/cid/ciaa130DOI Listing
March 2021

Gestational vitamin D and offspring risk of multiple sclerosis: a systematic review and meta-analysis.

Ann Epidemiol 2020 03 3;43:11-17. Epub 2020 Jan 3.

Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA.

Purpose: Our objective was to systematically review and meta-analyze studies that assessed the association between gestational vitamin D levels and risk of multiple sclerosis (MS) in offspring.

Methods: Embase and Pubmed databases were searched from inception to May 2018. Original, observational studies that investigated both clinically defined MS (in offspring) and vitamin D levels in utero or shortly after birth were included. Two reviewers independently abstracted data and assessed the quality of studies using the Newcastle-Ottawa Quality Assessment Scale. Summary effect estimates and 95% confidence intervals were calculated with random effects models using inverse variance weighting. Determinants of heterogeneity were evaluated.

Results: Four case-control studies of moderate to low risk of bias were included. Summary effect estimates of the effect of higher levels of gestational vitamin D on risk of offspring MS demonstrated a significant protective effect in random effects (OR: 0.63, 95% CI: 0.47, 0.84) models and in a stratified analysis based on study quality. Factors identified as determinants of heterogeneity were the definitions of vitamin D deficiency, the characteristics of study participants, and the quality of the study.

Conclusions: Sufficient levels of vitamin D during pregnancy may be protective against offspring's development of multiple sclerosis later in life.
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http://dx.doi.org/10.1016/j.annepidem.2019.12.010DOI Listing
March 2020

Bioaerosols generated from toilet flushing in rooms of patients with infection.

Infect Control Hosp Epidemiol 2020 05 31;41(5):517-521. Epub 2020 Jan 31.

Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, Iowa.

Background: Clostridioides difficile infection (CDI) is the most frequently reported hospital-acquired infection in the United States. Bioaerosols generated during toilet flushing are a possible mechanism for the spread of this pathogen in clinical settings.

Objective: To measure the bioaerosol concentration from toilets of patients with CDI before and after flushing.

Design: In this pilot study, bioaerosols were collected 0.15 m, 0.5 m, and 1.0 m from the rims of the toilets in the bathrooms of hospitalized patients with CDI. Inhibitory, selective media were used to detect C. difficile and other facultative anaerobes. Room air was collected continuously for 20 minutes with a bioaerosol sampler before and after toilet flushing. Wilcoxon rank-sum tests were used to assess the difference in bioaerosol production before and after flushing.

Setting: Rooms of patients with CDI at University of Iowa Hospitals and Clinics.

Results: Bacteria were positively cultured from 8 of 24 rooms (33%). In total, 72 preflush and 72 postflush samples were collected; 9 of the preflush samples (13%) and 19 of the postflush samples (26%) were culture positive for healthcare-associated bacteria. The predominant species cultured were Enterococcus faecalis, E. faecium, and C. difficile. Compared to the preflush samples, the postflush samples showed significant increases in the concentrations of the 2 large particle-size categories: 5.0 µm (P = .0095) and 10.0 µm (P = .0082).

Conclusions: Bioaerosols produced by toilet flushing potentially contribute to hospital environmental contamination. Prevention measures (eg, toilet lids) should be evaluated as interventions to prevent toilet-associated environmental contamination in clinical settings.
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http://dx.doi.org/10.1017/ice.2020.11DOI Listing
May 2020

Novel methodology to measure pre-procedure antimicrobial prophylaxis: integrating text searches with structured data from the Veterans Health Administration's electronic medical record.

BMC Med Inform Decis Mak 2020 01 30;20(1):15. Epub 2020 Jan 30.

VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), 150 S. Huntington Ave, Boston, MA, 02130, USA.

Background: Antimicrobial prophylaxis is an evidence-proven strategy for reducing procedure-related infections; however, measuring this key quality metric typically requires manual review, due to the way antimicrobial prophylaxis is documented in the electronic medical record (EMR). Our objective was to electronically measure compliance with antimicrobial prophylaxis using both structured and unstructured data from the Veterans Health Administration (VA) EMR. We developed this methodology for cardiac device implantation procedures.

Methods: With clinician input and review of clinical guidelines, we developed a list of antimicrobial names recommended for the prevention of cardiac device infection. We trained the algorithm using existing fiscal year (FY) 2008-15 data from the VA Clinical Assessment Reporting and Tracking-Electrophysiology (CART-EP), which contains manually determined information about antimicrobial prophylaxis. We merged CART-EP data with EMR data and programmed statistical software to flag an antimicrobial orders or drug fills from structured data fields in the EMR and hits on text string searches of antimicrobial names documented in clinician's notes. We iteratively tested combinations of these data elements to optimize an algorithm to accurately classify antimicrobial use. The final algorithm was validated in a national cohort of VA cardiac device procedures from FY2016-2017. Discordant cases underwent expert manual review to identify reasons for algorithm misclassification.

Results: The CART-EP dataset included 2102 procedures at 38 VA facilities with manually identified antimicrobial prophylaxis in 2056 cases (97.8%). The final algorithm combining structured EMR fields and text note search results correctly classified 2048 of the CART-EP cases (97.4%). In the validation sample, the algorithm measured compliance with antimicrobial prophylaxis in 16,606 of 18,903 cardiac device procedures (87.8%). Misclassification was due to EMR documentation issues, such as antimicrobial prophylaxis documented only in hand-written clinician notes in a format that cannot be electronically searched.

Conclusions: We developed a methodology with high accuracy to measure guideline concordant use of antimicrobial prophylaxis before cardiac device procedures using data fields present in modern EMRs. This method can replace manual review in quality measurement in the VA and other healthcare systems with EMRs; further, this method could be adapted to measure compliance in other procedural areas where antimicrobial prophylaxis is recommended.
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http://dx.doi.org/10.1186/s12911-020-1031-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6993312PMC
January 2020

Incidence and Outcomes Associated With Clostridium difficile Infections: A Systematic Review and Meta-analysis.

JAMA Netw Open 2020 01 3;3(1):e1917597. Epub 2020 Jan 3.

Carver College of Medicine, Department of Internal Medicine, University of Iowa, Iowa City.

Importance: An understanding of the incidence and outcomes of Clostridium difficile infection (CDI) in the United States can inform investments in prevention and treatment interventions.

Objective: To quantify the incidence of CDI and its associated hospital length of stay (LOS) in the United States using a systematic literature review and meta-analysis.

Data Sources: MEDLINE via Ovid, Cochrane Library Databases via Wiley, Cumulative Index of Nursing and Allied Health Complete via EBSCO Information Services, Scopus, and Web of Science were searched for studies published in the United States between 2000 and 2019 that evaluated CDI and its associated LOS.

Study Selection: Incidence data were collected only from multicenter studies that had at least 5 sites. The LOS studies were included only if they assessed postinfection LOS or used methods accounting for time to infection using a multistate model or compared propensity score-matched patients with CDI with control patients without CDI. Long-term-care facility studies were excluded. Of the 119 full-text articles, 86 studies (72.3%) met the selection criteria.

Data Extraction And Synthesis: Two independent reviewers performed the data abstraction and quality assessment. Incidence data were pooled only when the denominators used the same units (eg, patient-days). These data were pooled by summing the number of hospital-onset CDI incident cases and the denominators across studies. Random-effects models were used to obtain pooled mean differences. Heterogeneity was assessed using the I2 value. Data analysis was performed in February 2019.

Main Outcomes And Measures: Incidence of CDI and CDI-associated hospital LOS in the United States.

Results: When the 13 studies that evaluated incidence data in patient-days due to hospital-onset CDI were pooled, the CDI incidence rate was 8.3 cases per 10 000 patient-days. Among propensity score-matched studies (16 of 20 studies), the CDI-associated mean difference in LOS (in days) between patients with and without CDI varied from 3.0 days (95% CI, 1.44-4.63 days) to 21.6 days (95% CI, 19.29-23.90 days).

Conclusions And Relevance: Pooled estimates from currently available literature suggest that CDI is associated with a large burden on the health care system. However, these estimates should be interpreted with caution because higher-quality studies should be completed to guide future evaluations of CDI prevention and treatment interventions.
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http://dx.doi.org/10.1001/jamanetworkopen.2019.17597DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6991241PMC
January 2020

Perceived Benefits and Challenges of Ebola Preparation Among Hospitals in Developed Countries: A Systematic Literature Review.

Clin Infect Dis 2020 02;70(5):976-986

Department of Internal Medicine, Carver College of Medicine, Iowa City, Iowa.

The 2014-2016 Ebola epidemic in West Africa provided an opportunity to improve our response to highly infectious diseases. We performed a systematic literature review in PubMed, Cochrane Library, CINAHL, EMBASE, and Web of Science of research articles that evaluated benefits and challenges of hospital Ebola preparation in developed countries. We excluded studies performed in non-developed countries, and those limited to primary care settings, the public health sector, and pediatric populations. Thirty-five articles were included. Preparedness activities were beneficial for identifying gaps in hospital readiness. Training improved health-care workers' (HCW) infection control practices and personal protective equipment (PPE) use. The biggest challenge was related to PPE, followed by problems with hospital infrastructure and resources. HCWs feared managing Ebola patients, affecting their willingness to care for them. Standardizing protocols, PPE types, and frequency of training and providing financial support will improve future preparedness. It is unclear whether preparations resulted in sustained improvements. Prospero Registration. CRD42018090988.
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http://dx.doi.org/10.1093/cid/ciz757DOI Listing
February 2020

Risk of Recurrent Prosthetic Joint Infection in Rheumatoid Arthritis Patients-A Nationwide Cohort Study.

Open Forum Infect Dis 2019 Nov 19;6(11):ofz451. Epub 2019 Oct 19.

Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA.

Background: Treatment of rheumatoid arthritis (RA) often involves immune-suppressive therapies. Concern for recurrent prosthetic joint infection (PJI) in RA patients might be high and could reduce use of joint implantation in these patients. We aimed to evaluate the risk of recurrence of PJI in RA patients compared with osteoarthritis (OA) patients by utilizing a large health care system.

Methods: We conducted a retrospective cohort study of all patients admitted for a PJI who underwent debridement, antibiotics, and implant retention (DAIR) or 2-stage exchange (2SE) between 2003 and 2010 at 86 Veterans Affairs Medical Centers. Both RA patients and the comparison group of osteoarthritis (OA) patients were identified using , Ninth Revision, codes. All index PJI and recurrent positive cultures for during 2 years of follow-up were validated by manual chart review. A Cox proportional hazards regression model was used to compare the time to recurrent PJI for RA vs OA.

Results: In our final cohort of 374 veterans who had either DAIR or 2SE surgery for their index PJI, 11.2% had RA (n = 42). The majority of the cohort was male (97.3%), and 223 (59.6%) had a methicillin-susceptible PJI. RA patients had a similar risk of failure compared with OA patients, after adjusting for covariates (hazard ratio, 0.81; 95% confidence interval, 0.48-1.37).

Conclusions: Prior diagnosis of RA does not increase the risk of recurrent PJI. Further studies are needed to evaluate the effect of different RA therapies on outcomes of episodes of PJI.
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http://dx.doi.org/10.1093/ofid/ofz451DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6847211PMC
November 2019

Correlation of prevention practices with rates of health care-associated infection.

Infect Control Hosp Epidemiol 2020 01 29;41(1):52-58. Epub 2019 Oct 29.

William S. Middleton Memorial Veterans' Hospital, Madison, Wisconsin.

Objective: We examined Clostridioides difficile infection (CDI) prevention practices and their relationship with hospital-onset healthcare facility-associated CDI rates (CDI rates) in Veterans Affairs (VA) acute-care facilities.

Design: Cross-sectional study.

Methods: From January 2017 to February 2017, we conducted an electronic survey of CDI prevention practices and hospital characteristics in the VA. We linked survey data with CDI rate data for the period January 2015 to December 2016. We stratified facilities according to whether their overall CDI rate per 10,000 bed days of care was above or below the national VA mean CDI rate. We examined whether specific CDI prevention practices were associated with an increased risk of a CDI rate above the national VA mean CDI rate.

Results: All 126 facilities responded (100% response rate). Since implementing CDI prevention practices in July 2012, 60 of 123 facilities (49%) reported a decrease in CDI rates; 22 of 123 facilities (18%) reported an increase, and 41 of 123 (33%) reported no change. Facilities reporting an increase in the CDI rate (vs those reporting a decrease) after implementing prevention practices were 2.54 times more likely to have CDI rates that were above the national mean CDI rate. Whether a facility's CDI rates were above or below the national mean CDI rate was not associated with self-reported cleaning practices, duration of contact precautions, availability of private rooms, or certification of infection preventionists in infection prevention.

Conclusions: We found considerable variation in CDI rates. We were unable to identify which particular CDI prevention practices (i.e., bundle components) were associated with lower CDI rates.
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http://dx.doi.org/10.1017/ice.2019.290DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8559789PMC
January 2020

Current infection prevention and antibiotic stewardship program practices: A survey of the Society for Healthcare Epidemiology of America (SHEA) Research Network (SRN).

Infect Control Hosp Epidemiol 2019 09 17;40(9):1046-1049. Epub 2019 Jul 17.

Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine,University of Pennsylvania,Philadelphia, Pennsylvania.

We used a survey to characterize contemporary infection prevention and antibiotic stewardship program practices across 64 healthcare facilities, and we compared these findings to those of a similar 2013 survey. Notable findings include decreased frequency of active surveillance for methicillin-resistant Staphylococcus aureus, frequent active surveillance for carbapenem-resistant Enterobacteriaceae, and increased support for antibiotic stewardship programs.
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http://dx.doi.org/10.1017/ice.2019.172DOI Listing
September 2019

Impact of the pattern of interstitial lung disease on mortality in rheumatoid arthritis: A systematic literature review and meta-analysis.

Semin Arthritis Rheum 2019 12 15;49(3):358-365. Epub 2019 May 15.

Center for Comprehensive Access and Delivery Research & Evaluation, Iowa City VA, Iowa City, IA, USA.

Objective: An important extra-articular manifestation of rheumatoid arthritis (RA) is interstitial lung disease (ILD). The relationship between the usual interstitial pneumonia (UIP) pattern and mortality in patients with RA is unclear. The purpose of this study was to complete a systematic literature review and meta-analysis on the association between RA-ILD pattern and mortality risk.

Methods: We performed a systematic literature review through December 12, 2018. Study characteristics, unadjusted and adjusted relative risks (RR) of mortality for ILD pattern were extracted from the identified studies and quality assessments were performed. RR for mortality (RA-UIP vs. other RA-ILD) was pooled using inverse variance weighting and random effects models.

Results: Ten retrospective cohort studies met our eligibility criteria. A total of 1256 RA-ILD patients were included with 484 total deaths. Meta-analysis yielded a pooled RR of 1.66 (95% confidence interval1.07 to 2.56) for death among those with UIP RA-ILD compared with other patterns. In sub-group analysis when pooling studies comparing UIP to NSIP pattern of RA-ILD, the RR was 2.39 (95% CI 0.86-6.68).

Conclusion: Through a systematic literature review and meta-analysis, we found UIP pattern to be associated with a higher mortality risk in RA-ILD compared to other patterns of RA-ILD although more recent studies emphasize the importance of pulmonary physiology and the extent of lung involvement as significant predictors of mortality rather than the pattern of RA-ILD. Recognizing the small number of studies satisfying eligibility and inconsistent accounting for confounders, further study of mortality risk in RA-ILD is needed with standardized assessment of various RA, ILD, and patient-related factors.
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http://dx.doi.org/10.1016/j.semarthrit.2019.04.005DOI Listing
December 2019

Association between universal gloving and healthcare-associated infections: A systematic literature review and meta-analysis.

Infect Control Hosp Epidemiol 2019 07 17;40(7):755-760. Epub 2019 May 17.

Department of Epidemiology, College of Public Health,University of Iowa, Iowa City,Iowa.

Objective: Healthcare-associated infections (HAIs) are a significant burden on healthcare facilities. Universal gloving is a horizontal intervention to prevent transmission of pathogens that cause HAI. In this meta-analysis, we aimed to identify whether implementation of universal gloving is associated with decreased incidence of HAI in clinical settings.

Methods: A systematic literature search was conducted to find all relevant publications using search terms for universal gloving and HAIs. Pooled incidence rate ratios (IRRs) and 95% confidence intervals (CIs) were calculated using random effects models. Heterogeneity was evaluated using the Woolf test and the I2 test.

Results: In total, 8 studies were included. These studies were moderately to substantially heterogeneous (I2 = 59%) and had varied results. Stratified analyses showed a nonsignificant association between universal gloving and incidence of methicillin-resistant Staphylococcus aureus (MRSA; pooled IRR, 0.94; 95% CI, 0.79-1.11) and vancomycin-resistant enterococci (VRE; pooled IRR, 0.94; 95% CI, 0.69-1.28). Studies that implemented universal gloving alone showed a significant association with decreased incidence of HAI (IRR, 0.77; 95% CI, 0.67-0.89), but studies implementing universal gloving as part of intervention bundles showed no significant association with incidence of HAI (IRR, 0.95; 95% CI, 0.86-1.05).

Conclusions: Universal gloving may be associated with a small protective effect against HAI. Despite limited data, universal gloving may be considered in high-risk settings, such as pediatric intensive care units. Further research should be performed to determine the effects of universal gloving on a broader range of pathogens, including gram-negative pathogens.
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http://dx.doi.org/10.1017/ice.2019.123DOI Listing
July 2019
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