Infection Control & Hospital Epidemiology (2019), 40,358–361 doi:10.1017/ice.2018.339
Concise Communication
Preventability of hospital onset bacteremia and fungemia: A pilot study of a potential healthcare-associated infection outcome measure
Raymund B. Dantes MD, MPH1,2 , Clare Rock MBBCh3, Aaron M. Milstone MD, MHS4, Jesse T. Jacob MD5,
Sheri Chernetsky-Tejedor MD1, Anthony D. Harris MD, MPH6 and Surbhi Leekha MBBS, MPH6 1Division of Hospital Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, 2Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, 3Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of
Medicine, Baltimore, Maryland, 4Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, 5Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia and 6University of Maryland School of Medicine, Baltimore, Maryland, for the CDC Prevention Epicenter Program
Abstract
Hospital-onset bacteremia and fungemia (HOB), a potential measure of healthcare-associated infections, was evaluated in a pilot study among 60 patients across 3 hospitals. Two-thirds of all HOB events and half of nonskin commensal HOB events were judged as potentially prevent- able. Follow-up studies are needed to further develop this measure.
(Received 24 September 2018; accepted 27 November 2018)
Rates of central-line–associated bloodstream infections (CLABSIs) decreased 50% between 2008 and 2014 in the United States.1 CLABSI reporting to the Centers for Disease Control and Prevention’s National Healthcare Safety Network (NHSN) and use of the CLABSI data in Centers for Medicare and Medicaid Services (CMS) public reporting and pay for performance programs likely prompted enhanced infection prevention efforts to reduce CLABSI rates, though reductions since 2014 have diminished.2 CLABSIs are a subset of all hospital-onset bacteremia and fun-
gemia (HOB). Prior studies have speculated whether HOB could replace CLABSI as a performance measure that better measures patient safety and quality because it assesses all patients, not just those with central lines. HOB could theoretically drive further improvements in patient care and could be used for public report- ing. In prior studies, HOB rates decreased with CLABSI rates during implementation of CLABSI prevention bundles and may better differentiate performance across intensive care units (ICUs) compared to CLABSI. 3,4 The clinical relevance and preventability of CLABSIs, when
using evidence-based insertion and maintenance practices, led to its broad acceptance as a quality measure.5 In contrast, HOB has many more potential causes, encompassing infections at multi- ple anatomic sites and associated with many medical devices and procedures. The overall preventability of HOB is unknown; thus, determining the degree of preventability is critical to the potential use of HOB as a quality measure.
Author for correspondence: Raymund B. Dantes, Email: Raymund.dantes@
emoryhealthcare.org Cite this article: Dantes RB, et al. (2019). Preventability of hospital onset bacteremia and
fungemia: A pilot study of a potential healthcare-associated infection outcome measure. InfectionControl&Hospital Epidemiology, 40: 358–361,
https://doi.org/10.1017/ice.2018.339
© 2019 by The Society for Healthcare Epidemiology of America. All rights reserved. The aim of this study was to develop methods for determining
the infectious causes and preventability of HOB, with the goal of informing the design for a larger follow-up study.
Methods
TheHOBhas been defined as microorganism growth from a blood culture obtained at least 3 calendar days after hospital admission, when admission date is day 1. We included 20 HOB events each from 3 academic medical
centers. These eventswere randomly selected fromHOBs among all hospitalized adults (Emory University Hospital and the University of Maryland Medical Center) and critically ill chil- dren (Johns Hopkins Hospital) between October 1, 2014, and September 30, 2015. Physicians reviewed medical records to identify potential risk
factors and sources of bacteremia and fungemia from clinical docu- mentation. When medical record documentation was ambiguous, the physician reviewer was instructed to use clinical judgement to determine the most likely source. Two physician reviewers with infection prevention experience at each hospital used underlying patient factors, causative microorganism(s), source of infection, and other clinical data to rate the preventability of eachHOBevent on a 6-point Likert scale in an “ideal hospital” that practices “flaw- less infection control and patient care.” To support adjudication of preventability, a rating grid was created that listed the comparative risk of bacteremia due to underlying conditions on one axis and the likelihood of preventing the infection type under ideal conditions on the other axis (Fig. 1). For example, bacteremia resulting from mucosal-barrier injuries (low preventability) among immunosuppressed patients (high susceptibility) were suggested to be classified as “definitely not-preventable,” as previously
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