360
Table 1. (Continued ) Variable
CAUTI
Intra-abdominal abscess or peritonitis Ischemic bowel Other
Unknown NHSN-reported CLABSI Secondary bloodstream infection
Raymund B. Dantes et al
All Patients
No. 3 3 2 5 2
12 2
(%) (5) (5) (3) (8) (3)
(20) (3)
No. 1 2 0 2 0 3 0
UMMC
(%) (5)
(10) (0)
(10) (0)
(15) (0)
No. 0 1 1 2 2 7 2
JHH
(%) (0) (5) (5)
(10) (10) (35) (10)
No. 2 0 1 1 0 2 0
EUH %
(10) (0) (5) (5) (0)
(10) (0)
Note. EUH, Emory University Hospital; HOB, hospital-onset bacteremia and fungemia; JHH, Johns Hopkins Hospital; NHSN, National Healthcare Safety Network; UMMC, University of Maryland
Medical Center; CLABSI, central line-associated bloodstream infection; CAUTI, catheter-associated urinary tract infection; IQR, interquartile range; ICU, intensive care unit. aPediatric ICU patients in JHH were selected a priori. bIndicates presence within 2 days before or after the date of the blood culture. cOther indwelling devices included arterial line, biliary drain, chest tube, external ventricular drain, extracorporeal membrane oxygenation, fistula drain, gastrostomy tube, intra-aortic balloon pump, intraosseous line, intermittent urinary catheterization, jejunostomy tube, noninvasive high flow respiratory support system, nasogastric tube, surgical drain, ventricular assist device, and
ureteral stent. dInvasive procedures included bronchoscopy, cardiac catheterization, feeding tube placement, insertion of a tunneled hemodialysis central line, interventional radiology percutaneous procedure, and transesophageal echocardiogram.
(a) (b)
10 12 14 16 18
0 2 4 6 8
7(12%)
49% non- 5(12%)
commensal HOB preventable
Skin Commensals Non-Commensals
5(8%) 13(21%) 5(20%) 8(13%) 9(15%)
1(2%)
1.Definitely preventable
2.Moderately likely to be preventable
3.More likely preventable than not
0(0%)
4.Less likely preventable than not
5.Moderately likely not to be preventable
6.Definitely not
preventable
Fig. 1. Tool for adjudicating preventability of hospital onset bacteremia and fungemia (HOB) events (panel A), and HOB preventability across 3 academic medical centers, (panel B) (n=60).
described.6 In contrast, bacteremia resulting from CLABSIs (high preventability) in an otherwise healthy patient (low susceptibility) were suggested to be classified as “definitely preventable.” Reviewers could either review cases independently or together but were asked to reach a consensus on the preventability rating for each HOB event.
Results
The median hospitalization duration until the HOB event was 13 days (interquartile range [IQR] 7–24 days) among patients in pri- marily adult hospitals and 24 days (IQR, 9–60 days) among pedi- atric ICU patients. Half (50%) of adultHOBevents originated from ICUs (Table 1). Central venous catheters were frequently present in the time
period 2 days before and after blood cultures were obtained from patients (44 of 60, 73%). Presence of urinary catheters (20%) and invasive mechanical ventilation were less common (25%). Few HOB events (6 of 60, 10%) occurred among patients without any indwelling medical device, catheters or invasive mechanical ventilation (Table 1). Coagulase-negative staphylococci were the single most common organism identified among HOB events (17 of 60, 28%),
followed by Candida spp (7 of 60, 12%), methicillin-susceptible S. aureus (6 of 60, 10%), and Enterococcus spp (6 of 60, 10%) (Table 1). Clinical sources of HOB varied, and reviewers identified 14
separate categories of HOB sources during this study; the most common sources were nonmucosal barrier injury CLABSI (11 of 60, 28%), followed by skin contamination (11 of 60, 18%), and the respiratory tract (6 of 60, 10%) (Table 1). Overall, 38 of 60 HOB events (63%) were adjudicated as poten-
tially preventable; 17 were due to skin commensal organisms and attributed to contaminated blood
cultures.AmongHOBevents not due to skin commensal organisms, 21 of 43 of these HOB events (49%) were determined to be potentially preventable (Fig. 1). A minority (12 of 60, 20%) of all HOB events and potentially preventable HOB events (5 of 38, 13%) were reported to NHSN as CLABSI based on 2014 CDC definitions.
Discussion
In a pilot study, a variety of microorganisms and clinical sources were implicated in HOB events that were systematically evaluated by expert medical record reviewers. Approximately two-thirds of all HOB events and half of non-skin commensal HOB events were
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