Kalpana Gupta

• U.S. Department of Veterans Affairs

Background/Objectives: Recent in vitro data suggest that remdesivir might be less likely than nirmatrelvir–ritonavir to be associated with COVID-19 rebound. We compared the incidence of symptom rebound in our remdesivir-treated cohort with rates reported in the literature for nirmatrelvir–ritonavir. Methods: We performed a retrospective cohort stud...

Objective Many preoperative urine cultures are of low value and may even lead to patient harms. This study sought to understand practices around ordering preoperative urine cultures and prescribing antibiotic treatment. Design Open-ended, semi-structured qualitative interviews Setting 5 Veterans Affairs hospitals. Participants Interviews with 14...

Importance Although recent guidelines recommend against performance of preoperative urine culture before nongenitourinary surgery, many clinicians still order preoperative urine cultures and prescribe antibiotics for treatment of asymptomatic bacteriuria in an effort to reduce infection risk. Objective To assess the association between preoperativ...

Experimental evidence suggests that SARS-CoV-2 remains viable within aerosols with a half-life of approximately 1-3 hours, though changes in aerosol microenvironment may shorten viability to minutes. However, it remains unclear how long airborne SARS-CoV-2 can transmit infection. Whole genome sequencing of nasopharyngeal samples obtained from patie...

Background Detection of bacteriuria prior to most genitourinary (GU) procedures is a guideline-supported standard of care for prevention of postoperative UTI. Little is known about the frequency of concordance with guidelines and impact on outcomes. We hypothesized that GU surgeries in which a preoperative urine culture was indicated but not perfor...

Background Artificial Intelligence chatbots such as ChatGPT are increasingly being utilized for medical information by the public as well as by medical professionals, including researchers. We investigated the accuracy of information and citations generated by this search engine for a common medical condition, UTI. Methods This was a qualitative p...

Purpose: Recurrent cystitis guidelines recommend relying on a local antibiogram or prior urine culture to guide empirical prescribing, yet little data exist to quantify the predictive value of a prior culture. We constructed a urinary antibiogram and evaluated test metrics (sensitivity, specificity, and Bayes' positive and negative predictive valu...

Importance: While current evidence has demonstrated a surgical site infection (SSI) prevention bundle consisting of preoperative Staphylococcus aureus screening, nasal and skin decolonization, and use of appropriate perioperative antibiotic based on screening results can decrease rates of SSI caused by S aureus, it is well known that interventions...

Background: Unconfirmed penicillin allergies are common and may contribute to adverse outcomes, especially in frail older patients. Evidence-based clinical pathways for evaluating penicillin allergies have been effectively and safely applied in selected settings, but not in nursing home populations. Objective: To identify potential facilitators...

Sickness presenteeism among healthcare workers (HCW) risks nosocomial infection, but its prevalence among HCW with COVID-19 is unknown. Contemporaneous interviews revealed a sickness presenteeism prevalence of 49.8% among 255 HCW with symptomatic COVID-19. Presenteeism prevalence did not differ among HCW with and without specific COVID-19 symptoms...

This cohort study emulates a trial within a large national veteran population to assess the risk of adverse postoperative outcomes among patients with recent COVID-19 infection.

Background: Patients with recurrent urinary tract infections (rUTI) experience frequent exposure to antimicrobial regimens, leaving them at higher risk for developing antibiotic resistance. Little information on the prevalence of antibiotic resistance among patients with rUTI has been published. Although the IDSA recommends using a prior culture to...

Prophylaxis against spontaneous bacterial peritonitis (SBP) is recommended for select patients with cirrhosis, but long-term antibiotic therapy has risks. We evaluated concordance with guideline recommendations in 179 veterans with cirrhosis; 55% received guideline-concordant management of SBP prophylaxis. Despite stable guideline recommendations s...

Importance: Aerosol-borne SARS-CoV-2 has not been linked specifically to nosocomial outbreaks. Objective: To explore the genomic concordance of SARS-CoV-2 from aerosol particles of various sizes and infected nurses and patients during a nosocomial outbreak of COVID-19. Design, setting, and participants: This cohort study included patients and...

Initiation of NM/R treatment on Day 0 in a 71-year-old vaccinated and boosted male resulted in rapid resolution of COVID-19 symptoms followed one week later by the development of typical cold symptoms. SARS-CoV-2 viral load fluctuated in parallel with symptoms, with two distinct peaks on Day 1 and Day 9 of illness. No other respiratory pathogens we...

We describe relapse of COVID-19 symptoms and SARS-CoV-2 viral load following nirmatrelvir/ritonavir (NM/R) in 8 non-immunocompromised patients aged 31 to 71-years-old. Most patients improved rapidly after treatment with NM/R and had negative antigen or PCR tests prior to relapse on Days 9-12 of their illness. Relapse symptoms were described most fr...

We describe relapse of COVID-19 symptoms and SARS-CoV-2 viral load following nirmatrelvir/ritonavir (NM/R) in 10 non-immunocompromised patients aged 31 to 71-years-old. Most patients improved rapidly after treatment with NM/R and had negative antigen or PCR tests prior to relapse on Days 9-12 of their illness. Relapse symptoms were described most f...

Background Although many large, randomized controlled trials (RCT) have been conducted on antibiotic therapy for patients with primary C. difficile infections (CDI), few RCTs have been performed for patients with recurrent CDI (rCDI). In addition, fecal microbial transplant (FMT) is neither FDA-approved or guideline-recommended for patients with pa...

Objectives We characterized antibiotic prescribing patterns and management practices among recurrent urinary tract infection (rUTI) patients, and we identified factors associated with lack of guideline adherence to antibiotic choice, duration of treatment, and urine cultures obtained. We hypothesized that prior resistance to nitrofurantoin or trime...

Background In 2019, the IDSA Clinical Practice guidelines on asymptomatic bacteriuria (ASB) recommended that clinicians no longer screen or treat patients for ASB before non-urological surgeries. However, it remains to be seen whether these guideline recommendations alone will produce changes in practice. Understanding clinical decision-making abou...

Background Mesh explantation for infection after hernia surgery sets a cascade of events that has not been previously described. The purpose of this study is to review the care of these patients and outcomes. Methods We obtained data on all Veterans Health Administration enrollees undergoing hernia repair during 2008–2015. All mesh explantation ca...

Background Urine cultures are nonspecific for infection and often lead to misdiagnosis of urinary tract infection and unnecessary antibiotics. Diagnostic stewardship is a set of procedures that modifies test ordering, processing, and reporting in order to optimize diagnosis and downstream treatment. This study aimed to develop expert guidance on be...

Objective:. To estimate the relative risk of explantation in patients with skin and soft tissue infection onset within 90 days of hernia surgery, compared with days 91–365 and after 1 year. Background:. Infectious complications occurring after hernia repair with synthetic mesh require prolonged treatment, and eventual mesh explantation. Little is k...

Background: It is unclear if a history of mesh explantation for infection is predictive of future microbiology after subsequent hernia operations. We investigated how often the same causative organism is cultured in the initial explantation and subsequent repairs. Patients and Methods: We obtained data on patients undergoing ventral/incisional, umb...

Background: Recent reports indicate that vaccination is effective in reducing symptomatic infection with the Delta variant of SARS-CoV-2 (DV) but is less protective against asymptomatic transmission of DV in outpatients than for earlier variants. Here we report cryptic transmission associated with high DV viral load among vaccinated patients on an...

Background: Studies of antibiotic prescribing choice and duration have typically excluded women with recurrent UTI (rUTI), yet the Infectious Disease Society of America (IDSA) UTI treatment guidelines are applicable to recurrent and sporadic cystitis. We sought to better understand prescribing practices among uncomplicated rUTI patients in terms of...

Background Early convalescent plasma transfusion may reduce mortality in patients with non-severe coronavirus disease 2019 (COVID-19). Methods This study emulates a (hypothetical) target trial using observational data from a cohort of United States Veterans admitted to a Department of Veterans Affairs (VA) facility between May 1 and November 17, 2...

This cohort study of health care workers in a metropolitan Veterans Administration network examines the association of SARS-CoV-2 infection after receiving a single dose of mRNA-1273 vaccine compared with no vaccination.

Objective To develop a fully automated algorithm using data from the Veterans’ Affairs (VA) electrical medical record (EMR) to identify deep-incisional surgical site infections (SSIs) after cardiac surgeries and total joint arthroplasties (TJAs) to be used for research studies. Design Retrospective cohort study. Setting This study was conducted i...

Background Infectious complications after hernia surgery are potentially disastrous, often requiring long-term antibiotic, debridement, and mesh explantation. Our objective is to describe the long-term incidence and risk factors for synthetic mesh explantation due to infection after hernia surgery in a large cohort. Study Design Retrospective data...

Background Surgical site infections (SSIs) complicate nearly 6% of surgeries performed in Veterans Health Administration (VA) hospitals and occur despite adoption of practices known to reduce them. SSIs are associated with prolonged hospitalization and an increased risk of readmission, reoperation and mortality. Operating room (OR) door openings ma...

Background Prophylaxis against spontaneous bacterial peritonitis (SBP) is a guideline-recommended strategy; there are limited data on rates of concordance with guideline recommendations. We sought to evaluate rates of concordance, hypothesizing that antibiotics would overprescribed for prophylaxis against SBP. Methods This retrospective cohort stu...

Among 3926 healthcare personnel (HCP) in a multisite healthcare system, the minimal population prevalence of COVID-19 was 4.4% (bootstrap 95% CI 3.7%;5.0%), and the infection fatality rate was 0.6% (bootstrap 95% CI 0.0%;1.7%). Rates reflected both local community prevalence and hospital exposures but not specifically exposure on COVID-19 units.

Background: Skin and soft tissue infection (SSTI) after hernia surgery is infrequent yet catastrophic and is associated with mesh infection, interventions, and hernia recurrence. Although hernia repair is one of the most common general surgery procedures, uncertainty persists regarding incidence of long-term infections. Our goal is to develop a mac...

Background: Guidelines regarding asymptomatic bacteriuria (ASB) have consistently recommended against screening and treatment in most circumstances. However, screening of patients with spinal cord injury (SCI) is common practice and in some cases is a formal protocol at the organizational level. A previous study found that more than one-third of pa...

Background: Studies of interventions to decrease rates of surgical site infections (SSIs) must include thousands of patients to be statistically powered to demonstrate a significant reduction. Therefore, it is important to develop methodology to extract data available in the electronic medical record (EMR) to accurately measure SSI rates. Prior stu...

Objective: To validate the use of electronic algorithms based on International Classification of Diseases (ICD)-10 codes to identify outpatient visits for urinary tract infections (UTI), one of the most common reasons for antibiotic prescriptions. Methods: ICD-10 symptom codes (e.g., dysuria) alone or in addition to UTI diagnosis codes plus prescri...

The need for accurate antibody testing in patients following symptomatic or asymptomatic infections with SARS-CoV-2 is well documented.…

Adverse Effects of Nasopharyngeal Swabs: 3-D Printed Versus Commercial Swabs - Kalpana Gupta, Pamela Bellino, Michael E. Charness

Factors driving vancomycin surgical prophylaxis are poorly understood. In a national VA cohort with manually validated data, surgical specialty (cardiac, orthopedics) and perception of high facility MRSA prevalence-not MRSA colonization-- were the primary drivers of prescribing. Beta-lactam allergy was the second-most common reason. These data may...

In Reply We appreciate the comments from Chen et al regarding long-term outcomes in surgical patients with 30-day postoperative infections.¹ The authors are concerned that the inclusion of blood cultures that represent contamination rather than true infection may undermine the robustness of our conclusions. Fortunately, this is an issue that has be...

Procedure-related cardiac electronic implantable device (CIED) infections have high morbidity and mortality, highlighting the urgent need for infection prevention efforts to include electrophysiology procedures. We developed and validated a semi-automated algorithm based on structured electronic health records data to reliably identify CIED infecti...

Background: Clinical guidelines support early discontinuation of antimicrobials after cardiac device procedures; however, prolonged courses of antimicrobials are common. Methods: We conducted semistructured interviews with 13 electrophysiologists representing diverse geographic and clinical settings of care to identify perceived barriers and fac...

Background: Clostridioides difficile infection (CDI) causes significant morbidity in nursing home residents. Our aim was to describe adherence to a bundled CDI prevention initiative, which had previously been deployed nationwide in Veterans Health Administration (VA) long-term care facilities (LTCFs), and to improve compliance with reinforcement....

Importance Surgical site infection has been shown to decrease survival in veterans by up to 42%. The association of 30-day postoperative infections with long-term infections in the overall surgical population remains unknown. Objective To determine whether exposure to 30-day postoperative infection is associated with increased incidence of infecti...

Background Performing urinalyses and urine cultures in asymptomatic patients is one of the most common reasons for inappropriate antibiotic use. However, de-implementing this practice has been difficult, especially for clinical scenarios deemed to be high risk for infectious complications, such as among patients with delirium or those undergoing or...

Background Prior reports suggest that the use of vancomycin for surgical prophylaxis is common and increasing. However, rates of administration and reasons for choosing vancomycin are unknown. Thus, we sought to quantify the frequency of vancomycin as a surgical prophylaxis agent and to determine drivers of use. Methods All Veteran patients underg...

Background The US CDC has identified a number of antibiotic-resistant (AR) bacteria as urgent or serious public health threats. This study sought to quantify the prevalence and incidence of extended-spectrum β-lactamase (ESBL) Enterobacteriaceae (ENT), Carbapenem-resistant ENT (CRE), P. aeruginosa (Carb NS-PsA), vancomycin-resistant enterococci (VR...

Background Prolonged courses of antimicrobials are common following cardiac device procedures, but there are little data to explain drivers of this practice and factors that may facilitate change. Methods We conducted formative evaluations consisting of semi-structured, qualitative interviews with electrophysiologists (EP) to identify perceived ba...

Background Despite increased public health awareness of ESBLs and CRE, limited data exist regarding the true frequency of these resistant bacteria in urine cultures collected from adult patients in US hospitals. This study sought to quantify the prevalence and rates of ESBLs and CRE from urine cultures in adult hospitalized patients with ENT. Meth...

Background Nearly 40% of all peripherally inserted central catheter (PICC) placements may be inappropriate. Validated appropriateness criteria (Michigan Appropriateness Guide for Intravenous Catheters or MAGIC) were developed to improve patient safety and decrease adverse events from PICC line use. Recent studies have demonstrated the impact of MAG...

Importance Although hand hygiene (HH) is considered the most effective strategy for preventing hospital-acquired infections, HH adherence rates remain poor. Objective To examine whether the frequency of changing reminder signs affects HH adherence among health care workers. Design, Setting, and Participants This cluster randomized clinical trial...

Background: Little is known about health care workers' (HCW) perceptions of, or experiences using, respiratory protective equipment (RPE). We sought to characterize their perceptions and identify reasons underlying inappropriate use. Methods: We conducted 12 focus groups with nurses and nursing assistants at 4 medical centers. We analyzed the th...

Background: Urinalysis is a readily available test often used for screening. Pyuria is a common finding in asymptomatic patients, however, it is unknown how often identification of pyuria in the absence of confirmatory cultures leads to antimicrobial prescribing. Thus, the objective of this study was to measure the association between pyuria and a...

In Reply We appreciate the insights from Lipof et al about prosthetic joint infection prevention. The authors express concern that our findings may not extrapolate well to general orthopedic patients undergoing total joint replacement (TJR). Fortunately, many previous studies, including randomized clinical trials, similarly found that extended prop...

Background Postoperative infections are a common and often preventable complication of surgery. S. aureus is a prevalent organism cultured in these infections and is associated with morbidity, mortality, and increased healthcare utilization. However, the long-term burden of S. aureus infection in surgical patients is not well studied. The purpose o...

Objective To measure the association between receipt of specific infection prevention interventions and procedure-related cardiac implantable electronic device (CIED) infections. Design Retrospective cohort with manually reviewed infection status. Setting Setting: National, multicenter Veterans Health Administration (VA) cohort. Participants Sam...

Frequency of nursing home resident contact with staff, other residents, and the environment outside resident rooms - Volume 40 Issue 7 - Lisa Pineles, Eli N. Perencevich, Mary-Claire Roghmann, Kalpana Gupta, Jose Cadena, Gio Baracco, Christopher D. Pfeiffer, Graeme Forrest, Suzanne F. Bradley, Chris Crnich, Heather S. Reisinger, Daniel J. Morgan

Background The optimal approach for treating outpatient male urinary tract infections (UTI) is unclear. We studied the current management of male UTI in private outpatient clinics, and evaluated antibiotic choice, treatment duration, and the outcome of recurrence of UTI. Methods Visits for all male patients 18 years of age and older during 2011-20...

Asymptomatic bacteriuria (ASB) is a common finding in many populations, including healthy women and persons with underlying urologic abnormalities. The 2005 guideline from the Infectious Diseases Society of America recommended that ASB should be screened for and treated only in pregnant women or in an individual prior to undergoing invasive urologi...

Importance The benefits of antimicrobial prophylaxis are limited to the first 24 hours postoperatively. Little is known about the harms associated with continuing antimicrobial prophylaxis after skin closure. Objective To characterize the association of type and duration of prophylaxis with surgical site infection (SSI), acute kidney injury (AKI),...

Asymptomatic bacteriuria (ASB) is a common finding in many populations, including healthy women and persons with underlying urologic abnormalities. The 2005 guideline from the Infectious Diseases Society of America recommended that ASB should be screened for and treated only in pregnant women or in an individual prior to undergoing invasive urologi...

Importance Limited data suggest that screening for asymptomatic bacteriuria (ASB) prior to nonurologic procedures is not useful. However, high-quality evidence to support consensus recommendations and influence clinical practice is lacking. Objective To characterize the association between detection and treatment of preoperative ASB and postoperat...

Background The benefits of surgical antimicrobial prophylaxis are limited to the first 24 hours postoperatively. However, little is known about the harms associated with prophylaxis lasting for greater than 24 hours. Thus, we sought to characterize the relationship between duration of prophylaxis and key post-operative outcomes, including surgical...

Background Surveillance is an essential aspect of infection prevention. Despite the high morbidity and mortality associated with procedure-related Cardiac Implantable Electronic Device (CIED) infections, methods for identifying them are limited. The objective of this study was to develop an algorithm with electronic flags to facilitate detection of...

Background Fosfomycin (FOS) and NTF (NTF) are IDSA guideline approved drugs for acute cystitis in women. However, their activity against multi drug-resistant Gram-negatives may be driving increased use among inpatients with more complicated UTI. We evaluated trends in inpatient prescribing of these UTI-specific agents in the predominantly male popu...

Background Pyuria is often used as a surrogate for bacteriuria and may trigger antibiotic use even in the setting of negative cultures. The impact of preoperative pyuria on empirical antibiotic use and on postoperative outcomes has not been evaluated in large multisite studies. Thus, we investigated rates and outcomes associated with treated versus...

Background The optimal approach for treating outpatient male urinary tract infections (UTI) is unclear. We studied the current management of male UTI in private outpatient clinics, and evaluated antibiotic choice, treatment duration, and the outcome of recurrence of UTI. Methods Visits for all male patients 18 years of age and older during 2011–20...

Urinary tract infection (UTI) is one of the most commonly diagnosed types of bacterial infection, and is often treated with antibiotic therapy. Preventive approaches are needed to minimize unnecessary use of antibiotic therapy, which can contribute to the development of antibiotic resistant pathogens. The effect of the consumption of a daily cranbe...

Background The rate of cardiovascular implantable electronic device (CIED) infection is increasing coincident with an increase in the number of device procedures. Preprocedural antimicrobial prophylaxis reduces CIED infections; however, there is no evidence that prolonged postprocedural antimicrobials additionally reduce risk. Thus, we sought to qu...

(Abstracted from Am J Obstet Gynecol 2018;218(5):536–537) Results from several studies suggest that prophylactic use of combination antimicrobial regimens reduce postoperative surgical site infections (SSIs) after cesarean delivery and other surgical procedures. A recent study, however, reported that combination regimens were associated with increa...

A rapidly deployed ward-based screen and isolate initiative for C. difficile carriers during an outbreak averted 5 of 10 expected HA-CDI cases without identified harms. ARIMA modeling predicted a number needed to screen of 197 and to isolate of 4.4. Targeted C. difficile screening can be utilized for outbreak mitigation.

OBJECTIVE To directly observe healthcare workers in a nursing home setting to measure frequency and duration of resident contact and infection prevention behavior as a factor of isolation practice DESIGN Observational study SETTING AND PARTICIPANTS Healthcare workers in 8 VA nursing homes in Florida, Maryland, Massachusetts, Michigan, Washington,...

Setting a Research Agenda in Prevention of Healthcare-Associated Infections (HAIs) and Multidrug-Resistant Organisms (MDROs) Outside of Acute Care Settings - Volume 39 Issue 2 - Charlesnika T. Evans, Robin L. Jump, Sarah L. Krein, Suzanne F. Bradley, Christopher J. Crnich, Kalpana Gupta, Eli N. Perencevich, Mark W. Vander Weg, Daniel J. Morgan

Various nanomechanical movements of bacteria are currently being explored as an indication of bacterial viability. Most notably, bacterial movements have been observed to subside rapidly and dramatically when the bacteria are exposed to effective antibiotics. Thus, monitoring bacterial movements, if performed with high fidelity, could offer a path...

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 asso...

Urinary tract infections (UTIs) are common in both inpatient and outpatient settings. This article provides an evidence-based, clinically relevant overview of management of UTIs, including screening, diagnosis, treatment, and prevention. Conditions covered include acute cystitis (both uncomplicated and complicated), catheter-associated UTI, and asy...

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 ar...

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 s...

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 d...

Background: Surveillance is an effective strategy for reducing surgical site infections (SSIs); however, current identification methods are resource-intensive. Therefore, we sought to validate an electronic SSI triaging tool for detection of probable infections and identify operational barriers and challenges. Methods: A retrospective cohort stu...

Background The optimal regimen for perioperative antimicrobial prophylaxis is controversial. Use of combination prophylaxis with a beta-lactam plus vancomycin is increasing; however, the relative risks and benefits associated with this strategy are unknown. Thus, we sought to compare postoperative outcomes following administration of 2 antimicrobia...

STROBE checklist. (PDF)

Relative risks corresponding to the effect of antibiotic regimen on specific 30-day surgical site infection type (superficial or deep/organ space) incidence. (DOCX)

A priori analysis plan submitted to and approved by IRB. (DOCX)

Procedure codes included in the cohort. (DOCX)

Adjusted relative risks corresponding to the effect of antibiotic regimen on surgical site infection incidence, including VA-facility-level variables in the model. (DOCX)

Background Excessive prescribing of vancomycin among patients admitted to inpatient wards is a challenge for antimicrobial stewardship programs, especially in the setting of expanded screening programs for methicillin-resistant Staphylococcus aureus (MRSA). Studies examining factors associated with longer duration of vancomycin use are limited. Me...