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Antibiotic Use Highly Tied to C. diff In Hospitals
BY ETHAN COVEY
Antibiotic use is significantly associated with hospital-onset Clostridioides difficile infection (HO-CDI), according to data taken from a large cohort of U.S.-based acute care hospitals (ACHs).
The findings build upon previous research that reported on antibiotic usage and HO-CDI rates from 2006 to 2012 (Infect Control Hosp Epidemiol 2021 May 7. doi:10.1017/ ice.2021.151; bit.ly/3ojGVfc-IDSE).
“This study is important because it confirms and extends previous research on the association of broad-spectrum antibiotics and CDI,” said Sophia Kazakova, MD, PhD, a health scientist with the CDC’s Division of Healthcare Quality Promotion. “These findings should encourage clinicians, infection control and antibiotic stewardship programs to strengthen antibiotic use monitoring and continue to focus on reducing use across all classes of antibiotics to reduce CDI.”
The researchers reviewed data on adult discharge and inpatient charge records for antibiotic use, CDI testing and CDI treatment for 921 ACHs from Jan. 1, 2012, to Dec. 31, 2018, HO-CDI rates were calculated and compared with days of therapy (DOT) for seven antibiotic classes.
The results showed a clear association between higher levels of antibiotic use and rates of HO-CDI.
For every 50 DOT per 1,000 patient days increase in antibiotic use, HO-CDI rates increased by 2.8%. When looking at specific classes of antibiotics, 10 DOT per 1,000 patient days increases in the use of carbapenems, cephalosporins and piperacillin-tazobactam were associated with 1.3%, 0.6%, and 1.1% increases in the rate of HO-CDI, respectively.
New to this batch of data was information regarding the use of nucleic acid amplification testing (NAAT) for diagnosis. Upon examining temporal trends in hospital use of NAAT testing, the authors found that hospitals using only NAAT diagnostic tests for CDI had a 16% higher HO-CDI rate.
“Even when controlling for NAAT use and other known patient and hospital confounders, we found strong positive cross-sectional and temporal associations between CDI and total and class-specific antibiotic use,” Dr. Kazakova noted. “This indicates that future studies should include this factor in CDI models.” Among the four hospitals that decreased total antibiotic use during the study period by 30% or more, HO-CDI rates decreased by 40%. Decreases in fluoroquinolone and carbapenem use corresponded with annual decreases in HO-CDI rates of 4% to 7% and 4% to 8%, and decreases in cephalosporins, fluoroquinolones, and carbapenems corresponded with annual decreases in the HO-CDI rate of 4% to 16%.
Mohamed H Yassin, MD, PhD, an associate professor of medicine, University of Pittsburgh School of Medicine, told OR Management News that the paper showed that hospitals need to focus efforts on traditional infection prevention efforts as well as antibiotic stewardship programs to reduce unnecessary antibiotic use. “This paper sends a clear message to hospitals to increase their efforts further to reduce antibiotic use,” he said.
Dr. Kazakova added that additional study may help clarify appropriate antibiotic usage. “Since higher antibiotic use is associated with higher rates of CDI, more research into defining and quantifying inappropriate and unnecessary use would be valuable,” she said. ■
Machine Learning and SSIs
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To do so, Dr. Melton and her colleagues tested automated SSI-detection algorithms developed and validated using electronic health record (EHR) data from 8,883 patients at their institution, and then applied those algorithms to 1,473 patients at the University of California, San Francisco.
Looking at the detection of superficial, incisional, organ-space and total SSI complications, the researchers found no difference in area under the curve for any outcome. They concluded that the algorithms developed at one site are generalizable to another (J Am Coll Surg 2021;232[6]:P963-P971).
“Currently there is no standard way SSIs are documented in the EHR that would make it easier for a person to extract the data—if they are documented at all. Here, they’re using machine learning and AI to go through records looking for certain terms that correlate with the presence of an SSI, saying that the process of screening might be automated, with a particular advantage that the need to manually review low-risk cases might be eliminated,” Dr. Barie commented.
“Basically, they’ve developed a tool that makes it easier for the surveillance people to find these SSI cases accurately.”
So, what explains the discrepancy in generalizability between the two papers? Both Drs. Cima and Melton suspect it has to do with characteristics of the institutions, the types of patients they see and the way their surgeons practice, and the questions that each of the algorithms are designed to answer.
“In our case, it appears that what we used to build the model is robust and good, but it’s unclear if that would scale across the country. These were both academic health systems; it might be different at a smaller center, or with different patient populations or over time as surgical practices change,” Dr. Melton said.
“These are important questions that we’re going to need to be able to answer more and more.” ■
—Genevieve Melton-Meaux, MD, PhD
Pre-op Psychological Survey
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8. Discuss the patient’s usual way of coping with challenges.
A gentle, but effective way to approach this is by discussing how the patient usually deals with challenges and stressors. You might hope to hear approaches such as “I read up on things,” “I lean on my friends” and “My faith sustains me.” While usual perioperative support is still important here, such statements are a good foundation for the response to surgery. Responses like “I don’t know” and “I get pretty down” suggest a psychological infrastructure that would probably benefit from greater professional support.
9. Discuss current care and relationships with medical/nursing staff.
Despite best efforts, and for many reasons, patients don’t always perceive that they received the kind of care they expected. While never acceptable, frustration, anger, anxiety or fear of returning to a floor or team’s care is especially concerning going into surgery. A deteriorating relationship with staff is a risk for psychological morbidity.11
10. Discuss current/past counseling history and assess mental status.
Discussion of these last areas often is the most difficult and sensitive for both the surgeon and patient. Generalizing problems with the term “stress” (everyone has it!) can reduce intrusiveness. Asking “how are you doing” is an effective way to start and listen for current, acute or ongoing anxiety or depressive thinking. Surgeon discomfort here should not be a rationale for avoiding this assessment. It is often extremely valuable as a baseline in the face of postoperative concerns like delirium and other cognitive changes.
The preoperative psychological assessment has the potential to provide important information to the surgeon for optimizing patient readiness for surgery. Obviously when concerns are revealed, addressing them in some manner from reassurance to psychiatric/psychological consultation is indicated.
The ability, interest and comfort of surgeons to engage productively in such discussions will vary greatly. We are not suggesting a prescription for how to evaluate a patient psychologically, but rather the value of generally increasing awareness of the patient’s psychological state and needs. Again, we differentiate POPS from in-depth psychological, neuropsychological or psychiatric evaluations that are essential in certain surgical scenarios and clinical situations.
What is suggested is a thoughtful discussion with the patient. The content and extent are to be determined by each individual surgeon and situation. Some patients (with an avoidant coping style) will be reluctant to engage fully and they should not be pressed.3 However, completing a POPS through discussion allows an opportunity for unique concerns to emerge while cultivating the relationship. ■
—Dr. Asken is the director at Provider Well-Being, UPMC Central PA Region, Harrisburg, Pa. Dr. Ladie is a transplant surgeon and the vice chair, Department of Surgery, UPMC Central PA Region, Harrisburg, Pa.
