Infection Control & Hospital Epidemiology Table 1. (Continued ) Variable
S. aureus infection category SSTI
Myositis/osteomyelitis/ septic arthritis
Bacteremia/endocarditis Pneumonia Not specified
Treatment-related variables
MRSA treatment coverage, DOT/1,000 patient days
Top 5 antibiotics prescribed during hospital admission
Clindamycin Vancomycin Cefazolin
Ceftriaxone TMP/SMX
64,059 (55.2) 35,874 (60) 28,185 (50) 51,047 (43.9) 26,967 (45.1) 24,080 (42.7) 25,131 (21.6) 7,111 (11.9) 18,020 (32) 17,732 (15.3) 7,846 (13.1) 9,886 (17.5) 15,856 (13.7) 9,712 (16.3) 6,144 (10.9)
Note. IQR, interquartile range; ICU, intensive care unit; NICU, neonatal intensive care unit; SSTI, skin and soft-tissue infection; DOT, days of therapy; TMP/SMX, trimethoprim/sulfa-
methoxazole. aAll differences between groups were statistically significant. bUnless otherwise specified.
36.9 20.1 16.8
All S. aureus (n=116,152) No. (%)b
MRSA
(n=59,762) No. (%)b
MSSA
(n=56,390) No. (%)b
45,148 (38.9) 26,709 (44.7) 18,439 (32.7) 11,750 (10.1) 4,231 (7.1) 7,519 (13.3)
8,140 (7) 2,717 (4.5) 5,423 (9.6)
9,174 (7.9) 2,861 (4.8) 6,313 (11.2) 49,971 (43) 26,450 (44.3) 23,521 (41.7)
1489
decreases for clindamycin (14.32 to 7.5) and vancomycin (16.6 to 10.8) (Fig. 1B).
Discussion
In this study, we observed a 36% decrease for S. aureus hospi- talizations between 2009 and 2016. Notably, MRSA hospitaliza- tions decreased 52%, including a corresponding decrease in DOT for anti-MRSA antibiotics during the same period. Decreases in S. aureus hospitalizations detected in this study
were similar to findings from studies performed in other adult and pediatric inpatient populations.6,7 Anumberoffactors may contribute to these decreases: (1) earlier recognition of S. aureus infections (especially SSTIs) and initiation of appropriate therapy in outpatient settings, such as incision and drainage and/or targeted antibiotic therapy which might prevent hospi- talization and/or recurrences; (2) changes in the tendency to hospitalize patients with suspected staphylococcal infections such as SSTIs presenting to emergency departments; (3) increased provider confidence to manage infections in the outpatient settings, and (4) the possibility of reductions in transmission of MRSA due to better infection control strategies especially in community settings or due to changes in circu- lating MRSA clones or lower prevalence in the community. Future studies are warranted to determine whether MRSA infections at the community-level are also decreasing, how to
Fig. 1. (A) S. aureus hospitalization rate per 1,000 hospital admissions in 39 PHIS hospitals with continuous reporting, 2009–2016. (B) Days of therapy for the most commonly used antibiotics per patient day among S. aureus hospital admissions.
best measure the impact of infection control practices, and how SSTI visits in the emergency department might have also changed over time. This study has several limitations. First, we identified cases of
S. aureus using administrative coding and, though this method has been used in other studies, it has not been validated. To enhance specificity, we included an additional requirement of receipt of an antibiotic with activity against S. aureus during the hospitalization. Second, PHIS only includes hospitalized patients and therefore does not allow us to distinguish between hospital- onset versus community-onset infections or to address concurrent trends in outpatient care settings that might have contributed to our findings. When we looked at our “present on admission” flag, we found only 9.3% of all S. aureus infections were marked as “no.” Third, the generalizability of our findings to pediatric hospitalizations outside of freestanding children’s hos- pitals is uncertain including the possibility that some S. aureus hospitalizations may have shifted to hospitals not captured by PHIS. Despite these limitations, these results provide evidence of substantial and sustained decreases in pediatric S. aureus hospi- talizations, driven by declining MRSA hospitalizations. Further
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