Person: Branch-Elliman, Westyn
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Branch-Elliman
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Westyn
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Branch-Elliman, Westyn
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Publication Health and Economic Burden of Post-Partum Staphylococcus aureus Breast Abscess(Public Library of Science, 2013) Branch-Elliman, Westyn; Lee, Grace; Golen, Toni; Gold, Howard; Baldini, Linda M.; Wright, SharonObjectives: To determine the health and economic burdens of post-partum Staphylococcus aureus breast abscess. Study design We conducted a matched cohort study (N = 216) in a population of pregnant women (N = 32,770) who delivered at our center during the study period from 10/1/03–9/30/10. Data were extracted from hospital databases, or via chart review if unavailable electronically. We compared cases of S. aureus breast abscess to controls matched by delivery date to compare health services utilization and mean attributable medical costs in 2012 United States dollars using Medicare and hospital-based estimates. We also evaluated whether resource utilization and health care costs differed between cases with methicillin-resistant and -susceptible S. aureus isolates. Results: Fifty-four cases of culture-confirmed post-partum S. aureus breast abscess were identified. Breastfeeding cessation (41%), milk fistula (11.1%) and hospital readmission (50%) occurred frequently among case patients. Breast abscess case patients had high rates of health services utilization compared to controls, including high rates of imaging and drainage procedures. The mean attributable cost of post-partum S. aureus breast abscess ranged from $2,340–$4,012, depending on the methods and data sources used. Mean attributable costs were not significantly higher among methicillin-resistant vs. –susceptible S. aureus cases. Conclusions: Post-partum S. aureus breast abscess is associated with worse health and economic outcomes for women and their infants, including high rates of breastfeeding cessation. Future study is needed to determine the optimal treatment and prevention of these infections.Publication Does Adjunctive Tigecycline Improve Outcomes in Severe-Complicated, Nonoperative Clostridium difficile Infection?(Oxford University Press (OUP), 2017) LaSalvia, Mary; Branch-Elliman, Westyn; Snyder, Graham Michael; Mahoney, Monica V.; Alonso, Carolyn; Gold, Howard; Wright, SharonSevere Clostridium difficile infection is associated with a high rate of mortality; however, the optimal treatment for severe- complicated infection remains uncertain for patients who are not candidates for surgical intervention. Thus, we sought to evaluate the benefit of adjunctive tigecycline in this patient population using a retrospective cohort adjusted for propensity to receive tigecycline. We found that patients who received tigecycline had similar outcomes to those who did not, although the small sample size limited power to adjust for comorbidities and severity of illness.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 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 A Roadmap for Reducing Cardiac Device Infections: A Review of Epidemiology, Pathogenesis, and Actionable Risk Factors to Guide the Development of an Infection Prevention Program for the Electrophysiology Laboratory(Springer Science and Business Media LLC, 2017-08-16) Branch-Elliman, WestynPurpose of Review Cardiovascular implantable electronic device (CIED) infections are highly morbid, common, and costly, and rates are increasing (Sohail et al. Arch Intern Med 171(20):1821–8 2011; Voigt et al. J Am Coll Cardiol 48(3):590–1 2006). Factors that contribute to the development of CIED infections include patient factors (comorbid conditions, self-care, microbiome), procedural details (repeat procedure, contamination during procedure, appropriate pre-procedural prep, and antimicrobial use), environmental and organizational factors (patient safety culture, facility barriers, such as lack of space to store essential supplies, quality of environmental cleaning), and microbial factors (type of organism, virulence of organism). Each of these can be specifically targeted with infection prevention interventions. Recent Findings Basic prevention practices, such as administration of systemic antimicrobials prior to incision and delaying the procedure in the setting of fever or elevated INR, are helpful for day-to-day prevention of cardiac device infections. Small single-center studies provide proof-of-concept that bundled prevention interventions can reduce infections, particularly in outbreak settings. However, data regarding which prevention strategies are the most important is limited as are data regarding the optimal prevention program for day-to-day prevention (Borer et al. Infect Control Hosp Epidemiol 25(6):492–7 2004; Ahsan et al. Europace 16(10):1482–9 2014). Summary Evolution of infection prevention programs to include ambulatory and procedural areas is crucial as healthcare delivery is increasingly provided outside of hospitals and operating rooms. The focus on traditional operating rooms and inpatient care leaves the vast majority of healthcare delivery—including cardiac device implantations in the electrophysiology laboratory—uncovered.Publication When Sterile Processing Goes Down: An Economic Analysis of Alternative Strategies for Supporting the Service(Cambridge University Press (CUP), 2017-06-19) Mittenzwei, Susan E.; Topkoff, Jeannie L.; Bessesen, Mary T.; Porter, Clifford A.; Rai, Gurdev S.; Branch-Elliman, WestynGiven steam-quality challenges at our facility, the financial impact of options for reopening the sterile processing service unit were explored; duration of closure was the major driver of costs. Other potential negative effects of operating-room shutdowns include injury to facility reputation, loss of staff, loss of reimbursements, and harm to residency programs.Publication Investigation of a Candida guilliermondii Pseudo-Outbreak Reveals a Novel Source of Laboratory Contamination(American Society for Microbiology, 2017-04) Kirby, James; Branch-Elliman, Westyn; LaSalvia, Mary; Longhi, Lorinda; MacKechnie, Matthew; Urman, Grigoriy; Baldini, Linda M.; Muriel, Fatima R.; Sullivan, Bernadette; Yassa, David; Gold, Howard; Wagner, Trevor K.; Diekema, Daniel J.; Wright, SharonCandida guilliermondii was isolated from sterile specimens with increasing frequency over a several-month period despite a paucity of clinical evidence suggesting true Candida infections. However, a health care-associated outbreak was strongly considered due to growth patterns in the microbiology laboratory that were more consistent with true infection than environmental contamination. Therefore, an extensive investigation was performed to identify its cause. With the exception of one case, patient clinical courses were not consistent with true invasive fungal infections. Furthermore, no epidemiologic link between patients was identified. Rather, extensive environmental sampling revealed C. guilliermondii in an anaerobic holding jar in the clinical microbiology laboratory, where anaerobic plates were prereduced and held before inoculating specimens. C. guilliermondii grows poorly under anaerobic conditions. Thus, we postulate that anaerobic plates became intermittently contaminated. Passaging from intermittently contaminated anaerobic plates to primary quadrants of aerobic media during specimen planting yielded a colonial growth pattern typical for true specimen infection, thus obscuring laboratory contamination. A molecular evaluation of the C. guilliermondii isolates confirmed a common source for pseudo-outbreak cases but not for the one true infection. In line with Reason's model of organizational accidents, active and latent errors coincided to contribute to the pseudo-outbreak. These included organism factors (lack of growth in anaerobic conditions obscuring plate contamination), human factors (lack of strict adherence to plating order, leading to only intermittent observation of aerobic plate positivity), and laboratory factors (novel equipment). All of these variables should be considered when evaluating possible laboratory-based pseudo-outbreaks.Publication Using the Pillars of Infection Prevention to Build an Effective Program for Reducing the Transmission of Emerging and Reemerging Infections(Springer Science and Business Media LLC, 2015-07-01) Branch-Elliman, Westyn; Price, Connie Savor; Bessesen, Mary T.; Perl, Trish M.Preventing transmission of emerging infectious diseases remains a challenge for infection prevention and occupational safety programs. The recent Ebola and measles outbreaks highlight the need for pre-epidemic planning, early identification, and appropriate isolation of infected individuals and health care personnel protection. To optimally allocate limited infection control resources, careful consideration of major modes of transmission, the relative infectiousness of the agent, and severity of the pathogen-specific disease are considered. A framework to strategically approach pathogens proposed for health care settings includes generic principles (1) elimination of potential exposure, (2) implementation of administrative controls, (3) facilitation of engineering and environmental controls, and (4) protection of the health care worker and patient using hand hygiene and personal protective equipment. Additional considerations are pre-epidemic vaccination and incremental costs and benefits of infection prevention interventions. Here, major strategies for preventing health-care-associated transmissions are reviewed, including reducing exposure; vaccination; administrative, engineering, and environmental controls; and personal protective equipment. Examples from recent outbreaks are used to highlight key infection prevention aspects and controversies.Publication Determining the Ideal Strategy for Ventilator-associated Pneumonia Prevention. Cost–Benefit Analysis(American Thoracic Society, 2015-07-01) Branch-Elliman, Westyn; Wright, Sharon; Howell, Michael D.Rationale: Ventilator-associated pneumonia (VAP) is a common healthcare-associated infection with high associated cost and poor patient outcomes. Many strategies for VAP reduction have been evaluated. However, the combination of strategies with the optimal cost-benefit ratio remains unknown. Objectives: To determine the preferred VAP prevention strategy, both from the hospital and societal perspectives. Methods: A cost-benefit decision model with a Markov model was constructed. Baseline probability of VAP, death, reintubation, and discharge from the intensive care unit (ICU) alive were ascertained from clinical trial data. Model inputs were obtained from the medical literature and the U.S. Department of Labor; a device cost was obtained from the manufacturer. Sensitivity analyses were completed to test the robustness of model results. Measurements and main results: Overall least expensive strategy and the strategy with the best cost-benefit ratio, up to a willingness to pay threshold of $50,000-100,000 per case of VAP averted was sought. We examined a total of 120 unique combinations of VAP prevention strategies. The preferred strategy from the hospital perspective included subglottic suction endotracheal tubes, probiotics, and the Institute for Healthcare Improvement VAP Prevention Bundle. The preferred strategy from the point of view of society also included additional prevention measures (oral care with chlorhexidine and selective oral decontamination). No preferred strategies included silver endotracheal tubes or selective gut decontamination. Conclusions: Despite their infrequent use, current data suggest that the use of prophylactic probiotics and subglottic endotracheal tubes are cost-effective for preventing VAP from the societal and hospital perspectives.Publication Rates of Recurrent Variceal Bleeding Are Low with Modern Esophageal Banding Strategies: A Retrospective Cohort Study(Taylor & Francis, 2014) Branch-Elliman, Westyn; Sled, Sarah; Flamm, Steven; Perumalswami, Ponni; Factor, StephanieBackground: Variceal bleeding has a high rate of mortality and recurrence. Endoscopic band ligation (EBL) is the established standard of care for secondary prevention of variceal bleeding. Objective: To determine the long-term re-bleeding rate of an EBL protocol similar to current society guidelines. Design: We conducted a retrospective cohort study at a tertiary care center of all patients with a history of a variceal bleed who underwent an aggressive band ligation protocol. Interventions: At the time of sentinel bleed, all varices, regardless of size, were ligated. EBL was then repeated every 2 weeks until stabilization, and all visible varices were ligated. The interval between banding sessions then increased. Main Outcome Measurements: The incidence of re-bleeding was calculated as the time between clinical stabilization after the sentinel event until data censoring, which occurred at time of re-bleed, death, transplant, or loss-to-follow up. Gastric variceal bleeding was a secondary endpoint. Results: N=176 patients were treated with aggressive EBL, and followed for a median of 16 months (range, 3 months – 6.9 years). The 6 month incidence of re-bleeding was 2.3%, the 12 month incidence was 3.4%, and the 2 year incidence was 4.6%. Overall, aggressive EBL was well-tolerated. One patient died during follow up secondary to a gastric variceal bleed. Conclusions: Aggressive EBL yields a low rate of re-bleeding when compared to standard practice. Secondary prophylaxis with aggressive EBL should be a consideration for patients following a sentinel bleeding event.