Interventions to control MRSA: high time for time-series analysis?

Time-series methods are useful in quasi-experimental study designs in which rates of antibiotic-resistant infections are ascertained before and after an intervention. However, uncertainties remain regarding the use of time-series analysis as an appropriate research methodology for analysing the effect of infection control interventions and antibiotic policies on the epidemiology of methicillin-resistant Staphylococcus aureus (MRSA). In particular, there is still a substantial gap in our understanding of what actually happens to MRSA incidence when a planned intervention is made on use of one or more antibiotic drug classe

Carriage of Methicillin-Resistant Staphylococcus Aureus at Hospital Admission

Abstract Objectives: To measure the prevalence of, and to establish predictors for, the nasal carriage of methicillin-resistant Staphylococcus aureus (MRSA) at hospital admission. To evaluate mannitol-salt agar with oxacillin for the simultaneous detection and identification of MRSA from nasal swabs. Design: Three-month prospective case-control survey, with data collected from interviews and computerized databases. The criterion standard for MRSA detection was culture on Mueller-Hinton agar with oxacillin 6 μg/mL (National Committee for Clinical Laboratory Standards method). Setting: 320-bed tertiary-care hospital. Patients: 387 patients screened within 24 hours after admission, including 10 MRSA carriers (cases), 291 patients with no S aureus, and 86 patients with methicillin-susceptible S aureus. Results: The prevalence of MRSA nasal carriage was 2.6%, whereas the prevalence of carriage was 3.1% when both nasal and wound cultures were performed. The significant predictors of carriage were a prior detection of MRSA, open wounds, diabetes mellitus, treatments by injection, prior nursing home stays, visits at home by a nurse, and prior antibiotic treatments. Cases had stayed for longer periods in hospitals and had received longer antibiotic treatments within a year. Eighty patients (including the 10 cases) had diabetes, had been exposed to healthcare facilities within a year, and had antibiotics within 6 months. The sensitivity and negative predictive value of nasal swabs on mannitol-salt agar with oxacillin were 60% and 71%, respectively. Conclusion: MRSA carriage on admission to the hospital may be an increasing and underestimated problem. Further studies are needed to develop and validate a sensitive and specific prediction rul

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

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

Human factors and ergonomics in patient safety curriculum

The importance of teaching human factors and ergonomics (HFE) and patient safety is registered in two compelling facts: 1) the numbers of physicians who train in VA hospitals and 2) in the need for hospitals to function as highly reliable organizations. In the United States, more than half of the physicians‐in‐training do at least part of their medical school and residency training at veterans' health care facilities. Health care currently does not measure up to other high‐reliability organizations. By providing a HFE‐based patient safety curriculum, we hope to improve patient safety at the frontlines. We see the lasting benefit as residency programs that produce physicians who are competent, patient safety problem solvers throughout their careers who will assist health care organizations to become highly reliable. © 2011 Wiley Periodicals, Inc.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/89469/1/20282_ftp.pd

Using the Electronic Medical Record to Identify Community-Acquired Pneumonia: Toward a Replicable Automated Strategy

Background: Timely information about disease severity can be central to the detection and management of outbreaks of acute respiratory infections (ARI), including influenza. We asked if two resources: 1) free text, and 2) structured data from an electronic medical record (EMR) could complement each other to identify patients with pneumonia, an ARI severity landmark. Methods: A manual EMR review of 2747 outpatient ARI visits with associated chest imaging identified x-ray reports that could support the diagnosis of pneumonia (kappa score = 0.88 (95% CI 0.82∶0.93)), along with attendant cases with Possible Pneumonia (adds either cough, sputum, fever/chills/night sweats, dyspnea or pleuritic chest pain) or with Pneumonia-in-Plan (adds pneumonia stated as a likely diagnosis by the provider). The x-ray reports served as a reference to develop a text classifier using machine-learning software that did not require custom coding. To identify pneumonia cases, the classifier was combined with EMR-based structured data and with text analyses aimed at ARI symptoms in clinical notes. Results: 370 reference cases with Possible Pneumonia and 250 with Pneumonia-in-Plan were identified. The x-ray report text classifier increased the positive predictive value of otherwise identical EMR-based case-detection algorithms by 20–70%, while retaining sensitivities of 58–75%. These performance gains were independent of the case definitions and of whether patients were admitted to the hospital or sent home. Text analyses seeking ARI symptoms in clinical notes did not add further value. Conclusion: Specialized software development is not required for automated text analyses to help identify pneumonia patients. These results begin to map an efficient, replicable strategy through which EMR data can be used to stratify ARI severity

Problem of Selection in Law Libraries

Law libraries, like soap, come in three sizes -large, giant, and super. It is also true that law libraries, like taxes, living expenses, populations and college enrollments are rapidly expanding and the end is not in sight. Use determines the growth of a library. As long as students, professors and practitioners ask for more books, more periodicals and more services the library must expand

Book Review

Reviewing Max Lerner, America as Civilization; Life and Thought in the United States Today, Simon and Schuster, 195