First name
Aaron
Middle name
M
Last name
Milstone

Title

Association of a blood culture utilization intervention on antibiotic use in a pediatric intensive care unit.

Year of Publication

2019

Number of Pages

482-484

Date Published

2019 04

ISSN Number

1559-6834

Abstract

<p>Blood cultures are essential for the evaluation of sepsis. However, they may sometimes be obtained inappropriately, leading to high false-positive rates, largely due to contamination.1 As a quality improvement project, clinician decision-support tools for evaluating patients with fever or signs and symptoms of sepsis were implemented in April 2014 in our pediatric intensive care unit (PICU). This initiative resulted in a 46% decrease in blood culture obtainment2 and has been replicated in other institutions.3 It is important to evaluate antibiotic use as a balancing measure because a reduction in blood cultures could lead to an increase in antibiotic treatment days if clinicians continued empiric treatment in scenarios when blood culture results were not available. The objective of this study was to evaluate whether antibiotic use in the PICU changed in association with a reduction in blood culture utilization.</p>

DOI

10.1017/ice.2019.10

Alternate Title

Infect Control Hosp Epidemiol

PMID

30767809
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Title

Use of Human Factors and Ergonomics to Disseminate Health Care Quality Improvement Programs.

Year of Publication

2019

Number of Pages

117-118

Date Published

2019 Apr/Jun

ISSN Number

1550-5154

Abstract

<p>Human factors and ergonomics (HFE) is recognized as a key systems engineering approach to improve health care quality and safety. HFE is a scientific discipline that studies the interactions among people and other elements of a system and applies theory, principles, data, and methods to design in order to optimize the well-being of people and the overall system performance. An HFE approach to health care quality and safety emphasizes the deployment of HFE tools, knowledge, and professionals and the participation of local stakeholders in the design or redesign of health care work systems and processes to improve patient, employee, and organizational outcomes.</p>

DOI

10.1097/QMH.0000000000000211

Alternate Title

Qual Manag Health Care

PMID

30921286
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Title

Practices, Perceptions, and Attitudes in the Evaluation of Critically Ill Children for Bacteremia: A National Survey.

Year of Publication

2019

Number of Pages

Date Published

2019 Nov 06

ISSN Number

1529-7535

Abstract

<p><strong>OBJECTIVES: </strong>Sending blood cultures in children at low risk of bacteremia can contribute to a cascade of unnecessary antibiotic exposure, adverse effects, and increased costs. We aimed to describe practice variation, clinician beliefs, and attitudes about blood culture testing in critically ill children.</p>

<p><strong>DESIGN: </strong>Cross-sectional electronic survey.</p>

<p><strong>SETTING: </strong>Fifteen PICUs enrolled in the Blood Culture Improvement Guidelines and Diagnostic Stewardship for Antibiotic Reduction in Critically Ill Children collaborative, an investigation of blood culture use in critically ill children in the United States.</p>

<p><strong>SUBJECTS: </strong>PICU clinicians (bedside nurses, resident physicians, fellow physicians, nurse practitioners, physician assistants, and attending physicians).</p>

<p><strong>INTERVENTIONS: </strong>None.</p>

<p><strong>MEASUREMENT AND MAIN RESULTS: </strong>Survey items explored typical blood culture practices, attitudes and beliefs about cultures, and potential barriers to changing culture use in a PICU setting. Fifteen of 15 sites participated, with 347 total responses, 15-45 responses per site, and an overall median response rate of 57%. We summarized median proportions and interquartile ranges of respondents who reported certain practices or beliefs: 86% (73-91%) report that cultures are ordered reflexively; 71% (61-77%) do not examine patients before ordering cultures; 90% (86-94%) obtain cultures for any new fever in PICU patients; 33% (19-61%) do not obtain peripheral cultures when an indwelling catheter is in place; and 64% (36-81%) sample multiple (vs single) lumens of central venous catheters for new fever. When asked about barriers to reducing unnecessary cultures, 80% (73-90%) noted fear of missing sepsis. Certain practices (culture source and indication) varied by clinician type. Obtaining surveillance cultures and routinely culturing all possible sources (each lumen of indwelling catheters and peripheral specimens) are positively correlated with baseline blood culture rates.</p>

<p><strong>CONCLUSIONS: </strong>There is variation in blood culture practices in the PICU. Fear and reflexive habits are common drivers of cultures. These practices may contribute to over-testing for bacteremia. Further investigation of how to optimize blood culture use is warranted.</p>

DOI

10.1097/PCC.0000000000002176

Alternate Title

Pediatr Crit Care Med

PMID

31702704
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Title

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

Year of Publication

2019

Number of Pages

1-4

Date Published

2019 Jul 17

ISSN Number

1559-6834

Abstract

<p>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.</p>

DOI

10.1017/ice.2019.172

Alternate Title

Infect Control Hosp Epidemiol

PMID

31311610
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Title

Saving neonatal lives by improving infection prevention in low-resource units: tools are needed.

Year of Publication

2019

Number of Pages

010319

Date Published

2019 Jun

ISSN Number

2047-2986

Abstract

<p>Globally, neonatal mortality rates remain relatively stagnant despite overall progress in reducing under-5 mortality. In regions with highest mortality for neonates, infections account for up to 30%-50% of deaths. In many low and middle income countries (LMICs), births within health care facilities are encouraged as a mechanism to reduce both maternal and neonatal mortality. However, the resulting increased demand for facility births has not been accompanied by comparable increases in capacity for delivering quality care and enhancing the safety of maternal and neonatal patients. Shortages in space, trained staff, and consumable resources have frayed many maternal-neonatal health care settings. To date, there have been limited systematic efforts to improve quality of care, while demands on facilities expand.</p>

DOI

10.7189/jogh.09.010319

Alternate Title

J Glob Health

PMID

31217955
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Title

Central line-associated bloodstream infections in neonates with gastrointestinal conditions: developing a candidate definition for mucosal barrier injury bloodstream infections.

Year of Publication

2014

Number of Pages

1391-9

Date Published

2014 Nov

ISSN Number

1559-6834

Abstract

<p><strong>OBJECTIVE: </strong>To develop a candidate definition for central line-associated bloodstream infection (CLABSI) in neonates with presumed mucosal barrier injury due to gastrointestinal (MBI-GI) conditions and to evaluate epidemiology and microbiology of MBI-GI CLABSI in infants.</p>

<p><strong>DESIGN: </strong>Multicenter retrospective cohort study.</p>

<p><strong>SETTING: </strong>Neonatal intensive care units from 14 US children's hospitals and pediatric facilities.</p>

<p><strong>METHODS: </strong>A multidisciplinary focus group developed a candidate MBI-GI CLABSI definition based on presence of an MBI-GI condition, parenteral nutrition (PN) exposure, and an eligible enteric organism. CLABSI surveillance data from participating hospitals were supplemented by chart review to identify MBI-GI conditions and PN exposure.</p>

<p><strong>RESULTS: </strong>During 2009-2012, 410 CLABSIs occurred in 376 infants. MBI-GI conditions and PN exposure occurred in 149 (40%) and 324 (86%) of these 376 neonates, respectively. The distribution of pathogens was similar among neonates with versus without MBI-GI conditions and PN exposure. Fifty-nine (16%) of the 376 initial CLABSI episodes met the candidate MBI-GI CLABSI definition. Subsequent versus initial CLABSIs were more likely to be caused by an enteric organism (22 of 34 [65%] vs 151 of 376 [40%]; P = .009) and to meet the candidate MBI-GI CLABSI definition (19 of 34 [56%] vs 59 of 376 [16%]; P &lt; .01).</p>

<p><strong>CONCLUSIONS: </strong>While MBI-GI conditions and PN exposure were common, only 16% of initial CLABSIs met the candidate definition of MBI-GI CLABSI. The high proportion of MBI-GI CLABSIs among subsequent infections suggests that infants with MBI-GI CLABSI should be a population targeted for further surveillance and interventional research.</p>

DOI

10.1086/678410

Alternate Title

Infect Control Hosp Epidemiol

PMID

25333434
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Title

Daily chlorhexidine bathing to reduce bacteraemia in critically ill children: a multicentre, cluster-randomised, crossover trial.

Year of Publication

2013

Number of Pages

1099-106

Date Published

2013 Mar 30

ISSN Number

1474-547X

Abstract

<p><strong>BACKGROUND: </strong>Bacteraemia is an important cause of morbidity and mortality in critically ill children. Our objective was to assess whether daily bathing in chlorhexidine gluconate (CHG) compared with standard bathing practices would reduce bacteraemia in critically ill children.</p>

<p><strong>METHODS: </strong>In an unmasked, cluster-randomised, two-period crossover trial, ten paediatric intensive-care units at five hospitals in the USA were randomly assigned a daily bathing routine for admitted patients older than 2 months, either standard bathing practices or using a cloth impregnated with 2% CHG, for a 6-month period. Units switched to the alternative bathing method for a second 6-month period. 6482 admissions were screened for eligibility. The primary outcome was an episode of bacteraemia. We did intention-to-treat (ITT) and per-protocol (PP) analyses. This study is registered with ClinicalTrials.gov (identifier NCT00549393).</p>

<p><strong>FINDINGS: </strong>1521 admitted patients were excluded because their length of stay was less than 2 days, and 14 refused to participate. 4947 admissions were eligible for analysis. In the ITT population, a non-significant reduction in incidence of bacteraemia was noted with CHG bathing (3·52 per 1000 days, 95% CI 2·64-4·61) compared with standard practices (4·93 per 1000 days, 3·91-6·15; adjusted incidence rate ratio [aIRR] 0·71, 95% CI 0·42-1·20). In the PP population, incidence of bacteraemia was lower in patients receiving CHG bathing (3·28 per 1000 days, 2·27-4·58) compared with standard practices (4·93 per 1000 days, 3·91-6·15; aIRR 0·64, 0·42-0·98). No serious study-related adverse events were recorded, and the incidence of CHG-associated skin reactions was 1·2 per 1000 days (95% CI 0·60-2·02).</p>

<p><strong>INTERPRETATION: </strong>Critically ill children receiving daily CHG bathing had a lower incidence of bacteraemia compared with those receiving a standard bathing routine. Furthermore, the treatment was well tolerated.</p>

<p><strong>FUNDING: </strong>Sage Products, US National Institutes of Health.</p>

DOI

10.1016/S0140-6736(12)61687-0

Alternate Title

Lancet

PMID

23363666
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