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Publications (3)4.02 Total impact

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    ABSTRACT: Background: The surgical site infection (SSI) rate following Cesarean section (C-S) at The Johns Hopkins Hospital was above the national benchmark of 2.99 infections/100 procedures. We sought to improve the SSI rate via a multi-disciplinary intervention. Methods: A collaborative team of obstetrical (OB) physicians and nurses, the perinatal/perioperative clinical operations manager, anesthesia physicians, quality improvement specialists, infection preventionists, infectious disease physicians and hospital administrators initiated prevention efforts in late 2010. Intra-operative observations and monthly meetings were employed to generate infection prevention strategies. Interventions included reinforcement of adherence to evidence based practices for SSI prevention, aseptic technique, proper OR attire, surgical hand scrub, patient skin antisepsis, and maintenance of body temperature; direct feedback to individual surgeons regarding surgical technique and skin preparation for stat C-S; modification of prophylactic antibiotic dosing for patients weighing greater than 300 lbs., and standardization of skin antisepsis. Preoperative skin antisepsis was standardized and only performed by trained personnel. Reconfiguration of the OR suite eliminated unnecessary furniture and equipment, reduced crowding and improved protection of the sterile instrument table. OB physicians were educated about appropriate assessment and documentation of endometritis using a standardized definition. Surgeon-specific SSI rates were calculated and shared with the Chairman of OB and Gynecology. Results: There were 26 SSI following C-S procedures in CY2010 with a rate of 4.27 infections/100 procedures. After formation of the collaborative and implementation of SSI-prevention interventions, 12 SSI occurred in CY2011; the SSI rate decreased 52% to 2.06 (P=0.01). Conclusion: Implementation of comprehensive infection prevention assessments, education, and interventions through a collaborative, multidisciplinary team led to a significant reduction in the SSI rate following C-S procedures.
    IDWeek 2012 Meeting of the Infectious Diseases Society of America; 10/2012
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    ABSTRACT: Background: Misdiagnosis of ventilator-associated pneumonia (VAP) can lead to inappropriate antibiotic use, which can occur as the result of unnecessary as well as prolonged therapy. We sought to quantify and characterize appropriate and inappropriate antimicrobial use for VAP and identify risk factors for inappropriate use. Methods: Ventilated patients suspected of having VAP were prospectively identified in 6 adult ICUs between 12/15/09 and 12/15/10. All cases were assessed by an adjudication committee (AC) that included critical care, pulmonology, and infectious diseases specialists. The AC determined the appropriateness of the ICU team's VAP diagnosis and antimicrobial therapy using clinical, microbiologic and radiographic data including the Clinical Pulmonary Infection Score (CPIS) on the day of diagnosis, and day 3 and 8. Risk factors for inappropriate continuation of VAP therapy after day 3 were assessed using logistic regression. Results: 232 cases identified as possible VAP by the ICU teams occurred in 203 patients. On day 1, 94 (40.5%) cases were VAP by the AC and by day 3 only 73 cases were VAP by the AC. 82 (51.9%) cases without VAP on day 3 were continued on ABX despite no evidence of other infection, contributing 1193 excess antibiotic days (EADs), including 307 pip/tazo days, 296 vancomycin days, 213 cephalosporin days and 117 carbapenem days. ABX were continued for >8 days in 36 (49.3%) VAP cases, contributing 374 EADs. To assess targets for stewardship interventions, we compared ALL cases with (n = 120) and without (n = 35) inappropriate continuation of VAP therapy after day 3. Pressors on day 1 (OR 2.26, 95% CI 1.27, 9.77) and sputum culture obtained on day 3 (OR 3.53, 95% CI 1.27, 9.77) were associated with inappropriate continued VAP treatment. Positive sputum cultures, higher APACHE score, WBC, purulent secretions, infiltrate on x-ray, or high frequency suctioning were not. Conclusion: Inappropriate diagnosis and treatment of VAP resulted in 1567 days of EAD in one year in 6 ICUs. Clinical differences between patients without VAP who had antibiotics continued or discontinued were minimal, suggesting that clinician behaviors contribute to unnecessary prescribing. Strategies to improve the diagnosis of and antibiotic use for VAP are needed.
    IDWeek 2012 Meeting of the Infectious Diseases Society of America; 10/2012
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    ABSTRACT: To evaluate the impact of postprescription review of broad-spectrum antimicrobial (study-ABX) agents on rates of antimicrobial use. Quasi-experimental before-after study. Five academic medical centers. Adults receiving at least 48 hours of study-ABX. The baseline, intervention, and follow-up periods were 6 months each in 2 units at each of 5 sites. Adults receiving at least 48 hours of study-ABX entered the cohort as case-patients. During the intervention, infectious-diseases physicians reviewed the cases after 48 hours of study-ABX. The provider was contacted with alternative recommendations if antimicrobial use was considered to be unjustified on the basis of predetermined criteria. Acceptance rates were assessed 48 hours later. The primary outcome measure was days of study-ABX per 1,000 study-patient-days in the baseline and intervention periods. There were 1,265 patients in the baseline period and 1,163 patients in the intervention period. Study-ABX use decreased significantly during the intervention period at 2 sites: from 574.4 to 533.8 study-ABX days/1,000 patient-days (incidence rate ratio [IRR], 0.93; 95% confidence interval [CI], 0.88-0.97; P = .002) at hospital B and from 615.6 to 514.4 study-ABX days/1,000 patient-days (IRR, 0.83; 95% CI, 0.79-0.88; P < .001) at hospital D. Both had established antimicrobial stewardship programs (ASP). Study-ABX use increased at 2 sites and stayed the same at 1 site. At all institutions combined, 390 of 1,429 (27.3%) study-ABX courses were assessed as unjustified; recommendations to modify or stop therapy were accepted for 260 (66.7%) of these courses. Postprescription review of study-ABX decreased antimicrobial utilization in some of the study hospitals and may be more effective when performed as part of an established ASP.
    Infection Control and Hospital Epidemiology 04/2012; 33(4):374-80. · 4.02 Impact Factor