Person: Strymish, Judith
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Strymish
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Judith
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Strymish, Judith
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Publication 489Accuracy of Clinicians' Empiric Treatment Choices for Resistant Gram-Negative Uropathogens(Oxford University Press, 2014) Linsenmeyer, Katherine; Strymish, Judith; Gupta, KalpanaPublication 491Comparative Effectiveness of Single vs Combination Antibiotic Prophylaxis for TRUS-biopsy(Oxford University Press, 2014) Marino, Kaylee; Strymish, Judith; Parlee, Anne; Lerner, Lori; Orlando, Ralph; Gupta, KalpanaPublication MRSA Nasal Carriage Patterns and the Subsequent Risk of Conversion between Patterns, Infection, and Death(Public Library of Science, 2013) Gupta, Kalpana; Martinello, Richard A.; Young, Melissa; Strymish, Judith; Cho, Kelly; Lawler, Elizabeth VictoriaBackground: Patterns of methicillin-resistant S. aureus (MRSA) nasal carriage over time and across the continuum of care settings are poorly characterized. Knowledge of prevalence rates and outcomes associated with MRSA nasal carriage patterns could help direct infection prevention strategies. The VA integrated health-care system and active surveillance program provides an opportunity to delineate nasal carriage patterns and associated outcomes of death, infection, and conversion in carriage. Methods/Findings: We conducted a retrospective cohort study including all patients admitted to 5 acute care VA hospitals between 2008–2010 who had nasal MRSA PCR testing within 48 hours of admission and repeat testing within 30 days. The PCR results were used to define a baseline nasal carriage pattern of never, intermittently, or always colonized at 30 days from admission. Follow-up was up to two years and included acute, long-term, and outpatient care visits. Among 18,038 patients, 91.1%, 4.4%, and 4.6% were never, intermittently, or always colonized at the 30-day baseline. Compared to non-colonized patients, those who were persistently colonized had an increased risk of death (HR 2.58; 95% CI 2.18;3.05) and MRSA infection (HR 10.89; 95% CI 8.6;13.7). Being in the non-colonized group at 30 days had a predictive value of 87% for being non-colonized at 1 year. Conversion to MRSA colonized at 6 months occurred in 11.8% of initially non-colonized patients. Age >70 years, long-term care, antibiotic exposure, and diabetes identified >95% of converters. Conclusions: The vast majority of patients are not nasally colonized with MRSA at 30 days from acute hospital admission. Conversion from non-carriage is infrequent and can be risk-stratified. A positive carriage pattern is strongly associated with infection and death. Active surveillance programs in the year following carriage pattern designation could be tailored to focus on non-colonized patients who are at high risk for conversion, reducing universal screening burden.Publication Antibiotic Utilization in the Dental Clinic over 7 Years; Room for Improvement(Oxford University Press, 2017) Collison, Maggie; Gupta, Kalpana; Koch, George; O’Brien, William; Smith, Donald; Strymish, JudithAbstract Background: At least 30% of antibiotic courses prescribed in the outpatient setting are unnecessary, meaning that no antibiotic is needed at all. Specialty areas such as dental clinic are a common place for antibiotic use and a potential for antibiotic overuse. The duration and indications for antibiotic use in dental clinics have not been clearly defined, except in the setting of endocarditis prophylaxis. Antibiotics are often used and sometimes indicated for endodontic, periodontal, implant and surgical procedures. Our goal was to measure antibiotic usage and duration in the dental clinic at a large VA hospital. Methods: Outpatient antibiotic prescriptions from 2010–2016 for VA Boston were extracted from the VA data warehouse. Prescriptions were classified by date, antibiotic, and duration. Dental clinic visits and associated CPT codes were extracted for visits within 7 days +/- prescription. Results: Of 119,193 dental visits during the study period, 3.7% (4,358) were associated with a unique antibiotic prescription. CPT diagnoses included periodontal (17.1%), endodontic (5.1%), surgical (36.5%) and implant (26.2%) procedures. The antibiotics prescribed included amoxicillin (62.0%), clindamycin (17.7%), penicillin (10.5%), macrolides (4.3%), augmentin (3.4%), and in less than 1% other classes including fluoroquinolones (0.2%). Mean days of antibiotics were 7.6 +/- SD 5.2 days (7.4 +/- SD 4.0 days for the above CPT codes). Duration did not vary by diagnostic code or by antibiotic class. There were no temporal trends over time. Conclusion: The majority of antibiotic use in dental clinic was for diagnostic codes that may warrant antibiotic use. The spectrum of activity of agents is in keeping with guidelines. However, the duration of antibiotics is longer than what might be anticipated for prophylaxis of dental procedures or treatment of dental infections. Limitations include lack of manual chart review to identify specific indication and potential for missing prescriptions by non-dental providers. Surveillance and stewardship activities can optimize antibiotic use in dental clinic. Disclosures All authors: No reported disclosures.Publication Electronic Detection of MRSA Infections in a National VA Population Augments Current Manual Process(Oxford University Press, 2017) Strymish, Judith; Jones, Makoto; Evans, Martin; Branch-Elliman, Westyn; Robillard, Ernest; Chan, Jeffrey; Rosen, Amy; Gupta, KalpanaAbstract Background: Automated measurement of hospital-acquired infections (HAIs) can improve the efficiency and reliability of surveillance. Within the VA, inpatient MRSA HAIs are manually reviewed and reported to the Inpatient Evaluation Center (IPEC). These MRSA HAI metrics are used as part of facility rankings to compare quality. However, IPEC uses CDC surveillance definitions which may vary in interpretation across facilities and not reflect all clinically relevant MRSA events. Thus, we sought to compare this manual process to a previously-developed electronic algorithm for detecting clinical MRSA infections to evaluate whether the algorithm could be used to expand MRSA surveillance activities. Methods: Electronic data were extracted from the national VA healthcare system during the period from January 1, 2014–December 31, 2014. The electronic detection algorithm defined MRSA infections as a culture positive for MRSA from a sterile site or from a non-sterile site with receipt of an antimicrobial with MRSA activity ± 5 days from the date of culture collection. Cultures obtained ≥48 hours after admission were classified as HAI. IPEC data for five facilities was extracted and IPEC rates were compared with rates estimated by the electronic algorithm. Flagged infections at one facility were manually reviewed to evaluate any discordances. Results: N = 14,260 MRSA clinical cultures were identified in 9,209 unique patients. Of these, 1,703 met definition for MRSA HAI infection. Electronic algorithm detected MRSA HAI rates varied widely across 137 facilities (Figure 1), ranked by rate per 1,000 patient-days. IPEC rates were universally lower than estimates derived using the MRSA electronic detection tool. Discordance in the estimates was attributable to infections present on admission, differences in capture of surgical site infections, and differences between clinical and surveillance definitions of infection. Conclusion: Applying the MRSA algorithm provided additional information about the burden of MRSA infections across the VA. This algorithm could be used as a tool to complement IPEC reporting and further inform infection prevention activities. Disclosures All authors: No reported disclosures.Publication C. difficile Screening for Colonization among Surgical Ward Admissions Is Feasible and Useful(Oxford University Press, 2017) Linsenmeyer, Katherine; Brecher, Stephen; Strymish, Judith; O’Brien, William; Rochman, Alexandra; Itani, Kamal; Gupta, KalpanaAbstract Background: Identification of patients colonized with C. difficile (CDcol) upon admission and initiation of precautions has been shown to decrease hospital-acquired C. difficileinfection (HA-CDI) in a recent study. We implemented a quality improvement program screening new admissions to a surgical service and evaluated risk factors and outcomes associated with CDcol. Methods: Prospective cohort of all patients admitted to the surgical wards including ICU over a 6 month period 10/16–4/17. Upon admission, a perirectal swab was sent for C diff PCR. Patients with positive screens were placed on contact precautions. CDcol patients were not treated. Testing for CDI was done as usual practice only in patients with diarrhea. Main outcome was prevalence of CDcol and relationship to HA-CDI. Results: Of 708 surgical admissions, 585 (82.6%) patients were screened, 543 were eligible based on first admission; 19 (3.5%) were colonized. Recent surgical hospitalization (OR 13.2, 95% CI 3.4;52.1) and prior CDI (OR 19.5, 95% CI 2.9;127.7) were independent risk factors for CDcol. Antibiotic and PPI use were not associated. Of those with CDcol, 7 developed CDI (36.8%) compared with 5/524 (0.9%) screen negative patients (adj OR 60, 95% CI 12.6;286). CDcol combined with a prior h/o CDI allowed for detection of 8/12 (75%) cases of HA-CDI compared with 3/12 (25%) if only prior history was available. HA-CDI rates on surgical wards after one month post-implementation were 9.3/10,000 bed days of care compared with 12.2 in 2016 and 12.8 in 2015. No delays in bed flow were identified. Conclusion: Admission CDcol prevalence was low in our surgical VA population but was strongly associated with development of HA-CDI. Prior CDI was the strongest risk factor for CDcol and HA-CDI. Knowledge of prior CDI and CDcol status identified 75% of patients who developed CDI, 3 times more than knowledge of prior CDI alone. In certain settings, CDcol screening could improve detection and early isolation of potential CDiff spreaders. Implementation required significant support from administration, nursing and the laboratory, and was successful based on screening percentage without impact on bed flow. Impact on facility CDI rates remains to be fully demonstrated. Disclosures All authors: No reported disclosures.Publication National Cohort Study of Preoperative Bacteriuria, Surgical Prophylaxis, and Postoperative Outcomes(Oxford University Press, 2017) GallegosSalazar, Jaime; Strymish, Judith; Branch-Elliman, Westyn; Itani, Kamal; O’Brien, William; Gupta, KalpanaAbstract Background: Despite recommendations against screening urine for bacteriuria prior to non-urological surgery, it is still a common practice. If the urine culture (Ucx) is positive, clinicians often feel compelled to give targeted therapy or expand the peri-operative prophylaxis (PPX) regimen to cover the urinary organism. Large multicenter studies are lacking. We aimed to evaluate rates and results of preoperative urine screening and postoperative outcomes among a national cohort of surgical patients. Methods: All patients who underwent cardiac, orthopedic implant, or vascular surgery within the national VA health care system during the period from 10/1/08–9/30/13 and had the PPX regimen manually validated were included. Rates of positive Ucx and wound cultures during the 90-day post-operative period were compared between patients with and without pre-operative bacteriuria. Among patients with a positive pre-op urine culture the association between activity of surgical PPX and positive post-op cultures was evaluated. Results: N = 78,810 surgeries were evaluated (21,889 cardiac, 46,565 orthopedic implant, 10,356 vascular). A pre-op Ucx was performed in 26% (Fig); of these, 6.6% were positive and 852 (63%) received PPX active against the uropathogen. Positive pre-op Ucx was associated with higher rates of positive post-op Ucx and wound cultures (Fig). Among patients who received active PPX, post-op Ucx was positive in 46% compared with 39% who received inactive PPX. The rate of post-op wound cultures was not different between patients who received active (25%) vs. inactive (24%) PPX. The pre-op and post-op organisms were the same in 117/221 (52.9%) Ucx and 17/104 (16.3%) wound cultures, respectively. PPX activity did not affect the match rate. Conclusion: This is the largest, multicenter study demonstrating no difference in post-op urine and wound cultures in patients receiving active vs. inactive surgical PPX for pre-op bacteriuria. Prevalence of bacteriuria was similar to other surgical populations. Limitations include predominantly male population and need for further characterization of pre-op antibiotic therapy and UTI and SSI outcomes. Disclosures All authors: No reported disclosures.Publication 1631The Impact of Obesity of Clostidium difficile Recurrence(Oxford University Press, 2014) Lou, Uvette; Gupta, Kalpana; Strymish, Judith; Baker, Errol; Smith, Donald; Bhadelia, NahidPublication 306Switch from MRSA PCR to Agar for Nasal Screening Does Not Increase Transmission(Oxford University Press, 2014) Strymish, Judith; Robillard, Ernest; Gupta, KalpanaPublication Natural Language Processing for Real-Time Catheter-Associated Urinary Tract Infection Surveillance: Results of a Pilot Implementation Trial(Cambridge University Press (CUP), 2015-05-26) Branch-Elliman, Westyn; Strymish, Judith; Kudesia, Valmeek; Rosen, Amy K.; Gupta, KalpanaBACKGROUND Incidence of catheter-associated urinary tract infection (CAUTI) is a quality benchmark. To streamline conventional detection methods, an electronic surveillance system augmented with natural language processing (NLP), which gathers data recorded in clinical notes without manual review, was implemented for real-time surveillance. OBJECTIVE To assess the utility of this algorithm for identifying indwelling urinary catheter days and CAUTI. SETTING Large, urban tertiary care Veterans Affairs hospital. METHODS All patients admitted to the acute care units and the intensive care unit from March 1, 2013, through November 30, 2013, were included. Standard surveillance, which includes electronic and manual data extraction, was compared with the NLP-augmented algorithm. RESULTS The NLP-augmented algorithm identified 27% more indwelling urinary catheter days in the acute care units and 28% fewer indwelling urinary catheter days in the intensive care unit. The algorithm flagged 24 CAUTI versus 20 CAUTI by standard surveillance methods; the CAUTI identified were overlapping but not the same. The overall positive predictive value was 54.2%, and overall sensitivity was 65% (90.9% in the acute care units but 33% in the intensive care unit). Dissimilarities in the operating characteristics of the algorithm between types of unit were due to differences in documentation practice. Development and implementation of the algorithm required substantial upfront effort of clinicians and programmers to determine current language patterns. CONCLUSIONS The NLP algorithm was most useful for identifying simple clinical variables. Algorithm operating characteristics were specific to local documentation practices. The algorithm did not perform as well as standard surveillance methods.