News Scan for Oct 06, 2020

News brief

Diagnostic stewardship tied to fewer urine culture orders, hospital UTIs

A diagnostic stewardship program at a large Los Angeles hospital was associated with significantly reduced inpatient urine culture orders and rates of hospital-acquired catheter-associated urinary tract infections (CAUTIs), researchers reported today in Clinical Infectious Diseases.

The stewardship program was implemented by clinicians at the Los Angeles County + University of Southern California (LAC + USC) Medical Center after they conducted a review of all CAUTI cases and found that almost half of the positive urine cultures that triggered mandatory national CAUTI reporting were obtained as part of routine hospital-onset fever workup, rather than because the patient had signs or symptoms of an infection. The intervention involved a hospital-wide memo that educated providers on the overuse of urine culture testing and described criteria for appropriate inpatient urine culture ordering, along with monthly audit and feedback of urine culture orders.

To assess the impact of the program, researchers at LAC + USC Medical Center compared inpatient urine culture orders and the CAUTI standardized infection ratio (SIR) in the baseline period (January 2018 to January 2019) and the period after implementation of the diagnostic stewardship intervention (March 2019 to January 2020).

The results showed that inpatient urine culture orders dropped from an average of 509 per month in the baseline period to 280 per month after implementation, and the corresponding CAUTI SIR fell dramatically. There were no significant changes in the hospital's observed mortality for all patients or those patients with urinary tract infections, indicating that the intervention was not associated with any detectable patient harm. In addition, the reduction in urine cultures led to a projected lab expenditure reduction of $920 to $3,910 per month.

"We plan to continue measuring and sharing our hospital CAUTI SIR monthly, educating providers in grand rounds yearly, and educating nurse champions at our monthly CAUTI committee meeting," the authors write.
Oct 6 Clin Infect Dis abstract

Peer comparison linked to reduced antibiotic prescribing at VA hospital

A peer comparison–based antibiotic stewardship intervention at a Veterans Affairs (VA) emergency department (ED) was associated with reductions in overall and unnecessary oral antibiotic prescribing, researchers reported yesterday in Antimicrobial Agents and Chemotherapy.

In a prospective, observational cohort study, researchers with the VA Pittsburgh Healthcare System and the University of Pittsburgh evaluated oral antibiotic prescribing by ED physicians at the VA Pittsburgh Healthcare System before and after implementation of a peer comparison stewardship intervention.

The intervention involved staff education and emails sent to each ED clinician that compared their antibiotic prescribing rate to that of their peers. The peer comparison intervention was conducted from January 2018 through June 2018, and the study compared oral antibiotic prescriptions during that period with prescriptions during the baseline period (June 2016 through December 2017).

During the intervention period, antibiotic prescriptions decreased monthly by 10.4 prescriptions per 1,000 ED visits (P = 0.07), and the relative decrease in the trend of antibiotic prescriptions during the intervention period compared to baseline was 9.9 prescriptions per 1,000 ED visits per month (P = 0.07). The intervention was associated with a significant decrease in monthly amoxicillin-clavulanate and increase in cephalexin prescriptions. Also, decreasing trends in ciprofloxacin prescriptions during the baseline period were maintained during the intervention.

Unnecessary antibiotic prescribing decreased from 55.6% to 38.7% (a 30.4% decrease, P = 0.003) during the intervention, while optimal prescribing increased from 21.6% to 29.3% (a 35.8% increase, P = 0.12).

The authors note that while the intervention was associated with decreased overall and unnecessary antibiotic prescribing, rates of unnecessary prescribing remained high, and increases in the optimal prescribing did not reach statistical significance.

"These findings suggest that additional interventions beyond education and peer comparison may be needed in EDs to decrease rates of inappropriate antibiotic prescribing," they wrote.
Oct 5 Antimicrob Agents Chemother abstract

COVID-19 Scan for Oct 06, 2020

News brief

High rate of neurologic symptoms noted in hospitalized COVID-19 patients

A study yesterday found an 82.3% rate of neurologic symptoms among 509 hospitalized COVID-19 patients, with some symptoms associated with increased death rates.

SARS-CoV-2, the virus that causes COVID-19, appears to be unique among coronaviruses for its ability to cause multi-organ disease, including involvement of the brain and nervous system. A wide range of neurologic manifestations have been observed in COVID-19 patients, including headaches, dizziness, loss of taste or smell, and encephalopathy—a neurologic condition affecting the brain that can lead to altered mental states, confusion, and memory issues.

Researchers examined neurologic manifestations in 509 COVID-19 patients admitted to hospitals in the Chicago area to assess neurologic symptoms and determine if encephalopathy is associated with an increased risk of morbidity and mortality.

Neurologic symptoms were present at COVID-19 onset in 215 patients (42.2%), at hospital admission in 319 patients (62.7%), and at any time during the course of the disease in 419 patients (82.3%). The most frequent neurologic symptoms were myalgias (muscle aches), headaches, encephalopathy, dizziness, and loss of taste and smell.

Patients presenting with neurologic symptoms were younger than those without, and had a longer time from disease onset to hospitalization. Patients with encephalopathy were older, had a shorter time from onset to hospitalization, and were more likely to be male and have other comorbidities. Patients with neurologic symptoms had longer hospitalization stays, with encephalopathy patients experiencing triple the length of stay as those without neurologic symptoms.

The study authors found no significant differences in functional outcome or mortality at discharge for patients experiencing neurologic symptoms with the exception of encephalopathy patients, who showed lower functional outcomes and greater likelihood of death 30 days after hospitalization (adjusted odds ratio 2.92, 95% confidence interval 1.17, 7.57; P = 0.02).

"Only 9 months into the pandemic, the long-term effects of Covid-19 on the nervous system remain uncertain. Our results suggest that, of all neurologic manifestations, encephalopathy is associated with a worse functional outcome in hospitalized patients with Covid-19, and may have lasting effects," the study authors wrote.
Oct 5 Ann Clin Transl Neurol study

Women more likely to embrace COVID-19 prevention behaviors

A report in Behavioral Science & Policy finds that women are more likely than men to embrace preventive public health practices, including physical distancing, mask wearing and hand hygiene, to combat COVID-19.

The report details the findings of three studies showing gender differences in pandemic-related behavior during the peak period of the pandemic in the United States: an 800-participant online survey of public health behaviors, an observational study of mask wearing among 300 pedestrians in three large metro areas, and a county-level analysis of movement using anonymous cell phone data from 15 million users nationwide.

The researchers found that women surveyed were more likely to report following practices such as physical distancing, staying at home, frequent hand washing, and limiting in-person contact with family and friends. Women were also more likely than men to report relying on medical experts, other countries' experiences, their governor, and social media as sources of information to inform their practices.

"Previous research before the pandemic shows that women had been visiting doctors more frequently in their daily lives and following their recommendations more so than men," said lead author Irmak Olcaysoy Okten, PhD, in a New York University press release. "They also pay more attention to the health-related needs of others. So it's not surprising that these tendencies would translate into greater efforts on behalf of women to prevent the spread of the pandemic," Okten wrote.

The study also found a greater proportion of mask wearing among women pedestrians (57.7%) than men (42.3%) in New York City, New Haven, CT, and New Brunswick, NJ, even though gender distributions in these areas are roughly equivalent.

Nationwide GPS location data from cell phone users showed men practicing comparatively less physical distancing than women from Mar 9 to May 29 as measured by movement and visits to nonessential retailers, even after accounting for COVID-19 cases per capita, stay-at-home orders, demographics, gender differences in employment in various professions, and political affiliation.

The study authors caution that these findings may place men at higher risk of catching and spreading COVID-19. "Fine-tuning health messages to alert men in particular to the critical role of maintaining social distancing, hygiene, and mask wearing may be an effective strategy in reducing the spread of the virus," Okten says.
Oct 4 Behav Sci Policy report
Oct 5 New York University news release

Study finds intubation, extubation produce fewer aerosols than a cough

In a study published today in Anaesthesia, researchers measured how many aerosols are produced during intubation and extubation, which have both been considered a high-risk aerosol-generating procedure (AGP) during anesthesia for COVID-19.

Best practices have been to wear high-level personal protective equipment (PPE) and go through extensive operating room cleaning, slowing down operations, but this study found that the AGPs' maximum aerosol production was still less than 25% of the aerosol created by a voluntary cough.

Intubation involves inserting an artificial ventilation tube into the trachea to enhance breathing, and extubation refers to the removal of that tube.

Researchers from the North Bristol NHS Trust and the University of Bristol conducted their tests in ultraclean ventilation operating theaters on non–COVID-19 patients and went through face-mask ventilation, airway suction, repeated attempts of intubation, and extubation to reflect a real clinic setting with providers of varying experience. In all, they measured 19 intubations and 14 extubations.

Using high-resolution environmental monitoring, the scientists found that intubation created one-one thousandth the amount (0.001) of aerosol of a large cough and that extubation, even when accompanied by a weak cough, produced less than 25% of aerosols of a voluntary cough. To reduce the potential risk, the authors suggested that operators use practices to mitigate the patient's involuntary coughing or to simply step away from the face and behind the patient's head during extubation.

Although they concede the study worked off the aerosol/COVID-19 correlation and did not look at SARS-CoV-2 directly, the authors said in a news release, "If we can agree these procedures do not generate aerosols we can reduce the PPE we wear and we can eliminate the major delays that currently exist between one patient leaving the operating room and starting the next case."
Oct 6 Anaesthesia study