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Background: The National Healthcare Safety Network (NHSN) Antibiotic Use (AU) Option aids hospital antimicrobial stewardship programs (ASPs) by facilitating tracking and reporting of AU data. In 2021, the Tennessee Department of Health (TDH) launched an AU data quality project to improve reporting accuracy. Quarterly reports are generated, assessing data across 15 quality flags, such as reporting antimicrobial days when days present (DP) are zero or drug-route mismatches. Flags also highlight significant outliers, including DP or AU rates outside the median ±2 interquartile ranges compared to the prior year. Reporting facilities receive actionable solutions for flagged concerns. Method: Data from AU quality flag reports generated by the NHSN AU Option for Tennessee facilities (2021–2023) were analyzed in this cross-sectional study. The analysis summarized the frequency and distribution of flagged issues across facilities and time. Archived data were utilized, excluding updates facilities made after quarterly reports. Quarterly flags per category were calculated for each facility, with total flags compiled annually to determine category frequency and percentage. Additionally, the number of distinct facilities contributing to the annual flag count was evaluated, providing insights into data quality trends across the study period. Result: From 2021 to 2023, 97 facilities submitted data to the NHSN AU Option, resulting in 7336 flags identified in the AU quality reports (Figure 1). The most frequent flag was “location-level AU rate greater than outlying upper boundary” (n=1677, 22.9%), reported by 67 facilities and the highest reported in 2023 (n=722, 23.8%). The second was “location-level DP greater than outlying upper boundary” (n=1588, 21.6%), reported by 68 facilities and highest in 2021 (n=547, 23.5%). The most frequent non-outlier-based quality issue was “antimicrobial days reported for any drug when DP were reported as zero” (n=439, 6.0%) followed by “antimicrobial days for a single drug greater than DP” (n=48) Conclusion: The study reveals data quality concerns in AU reporting among Tennessee facilities. Flags with changes in “Location-Level Days Present” and “AU Rate” outliers being prominent across the study period. These findings underscore the need for continuous monitoring and targeted feedback to enhance data accuracy, as well as a need for antimicrobial stewardship personnel to be able to identify and address changes in prescribing patterns and patient populations efficiently within their facilities. Addressing recurring challenges identified can improve AU data reliability, supporting more effective antimicrobial stewardship and better patient care outcomes.

Background: Tracking antimicrobial use (AU) is a Core Element of Hospital Antimicrobial Stewardship Programs and important to help curb the public health threat of antimicrobial resistance. The National Healthcare Safety Network’s (NHSN) AU Option serves as a way for facilities, healthcare systems, and health departments to track and report AU rates within their jurisdictions. Many analyses at the state and national levels do not assess unit-level AU rates. This study investigates AU rates among patient care units in Tennessee reporting facilities from 2015 to 2023 and the most frequently used antimicrobial agents based on AU rates within select unit types. Methods: A retrospective analysis was conducted utilizing data obtained from the NHSN AU Option for inpatient units in Tennessee acute care hospitals. Units were defined as critical care (including neonatal), ward, oncology ward, stepdown, operating room (OR), and mixed acuity and specialty care areas, termed ‘other’. Unit types with fewer than five facilities represented were excluded. AU rates were determined by Antimicrobial Days of Therapy (DOT) per 1000 Days Present (DP). Statistical analyses , including descriptive statistics and comparison among the units by ANOVA test , were calculated using SAS Version 9.4. Results: Eighty-three facilities reported at least one month of data into the NHSN AU Option between 2015–2023. Among 70 facilities reporting inpatient units, the highest AU rate was observed in oncology ward units (n=12, 1114.6 DOT/1000 DP). A significant difference in AU rates was observed between oncology ward units compared to different unit types (p < 0 .001). Vancomycin, ceftriaxone, and piperacillin/tazobactam were the most used antimicrobials with AU rates of 83, 76, and 65 DOT/1000 DP, respectively. Vancomycin AU rates were significantly higher in oncology ward units compared to stepdown, ward, other, and OR units (p < 0 .0001). Ceftriaxone AU rate was significantly higher in stepdown units compared to oncology ward, other, and OR units (p < 0 .0001). Piperacillin/tazobactam AU rate was significantly higher in critical care units compared to different unit types (p < 0 .0001). Conclusion: During the study period, the AU rate varied across hospital inpatient units in Tennessee, with the highest AU rate in oncology wards. This unit-specific approach is critical to address the diverse antimicrobial prescribing behaviors observed, indicating that interventions should be customized to each unit’s distinct antimicrobial usage patterns for successful stewardship efforts. Targeted strategies focused on individual wards rather than facility-wide initiatives appear essential for effective reduction in antibiotic usage.

Background: Carbapenem-resistant Enterobacterales (CRE) have become an increasing public health challenge in the United States over the past two decades. Carbapenemase-producing CREs (CP-CREs) significantly contribute to the spread of antimicrobial-resistant pathogens in healthcare settings. Tennessee has been conducting surveillance of CRE since 2011. As part of the Emerging Infections Program (EIP), the state has participated in population-based surveillance in Davidson and seven surrounding counties, collaborating with the Centers for Disease Control and Prevention (CDC) since 2014. Methods: The data collected through the Muti-site Gram-negative Surveillance Initiative (MuGSI) project, a collaboration between Tennessee and CDC as part of EIP, was used for this study. The analysis was performed on a subset of CRE isolates tested for carbapenemase production (CP) among all incident CRE cases collected from 2016 to 2022. Incident CRE cases are defined as the identification of carbapenem-resistant E. coli, Enterobacter cloacae complex, and Klebsiella species (K. aerogenes, K. oxytoca, K. pneumoniae, and K. variicola) from urine or normally sterile specimens (e.g., blood) from the residents of the surveillance area in a 30-day period. The mortality data was obtained from the Tennessee Vital Registry and merged with the surveillance data. Cox regression analysis was performed to evaluate if there is a difference in the 90-day survival rate based on the CP status of the pathogen, gender, age group, and the Charlson comorbidity index (CCI) score. Data analysis was done using SAS version 9.4. Results: There were 570 CRE cases reported during the study period (2016-2022). Of these, 406 were tested for carbapenemase production and 87 (21.4%) were positive for CP. There were 269 (66.3%) females and 137 (33.7%) males. Patients with higher Charlson comorbidity index score (> = 5) have significantly higher hazard ratios compared to those with low scores (HR 4.17; p-value) Conclusion: This study indicates that patients infected with CP-CRE, females, and those with high Charlson comorbidity index score have a significantly higher probability of dying within 90 days. These factors are worth considering when conducting a risk assessment of patients infected with drug-resistant gram-negative bacilli. The significantly increased risk of death among patients infected with CP-CRE highlights the need for timely carbapenemase testing and use of the test result for appropriate antimicrobial therapy and infection prevention.

The number of ambulatory patients seeking treatment for skin and skin structure infections (SSSI) are increasing. The objective of this study is to determine recent trends in hospital admissions and healthcare resource utilization and identify covariates associated with hospital costs and mortality for hospitalized adult patients with a primary SSSI diagnosis in the United States. We performed a retrospective cross-sectional analysis (years 2005-2011) of data from the US Healthcare Cost and Utilization Project National Inpatient Sample. Recent trends, patient characteristics, and healthcare resource utilization for patients hospitalized with a primary SSSI diagnosis were evaluated. Descriptive and bivariate analyses were conducted to assess patient and hospital characteristics. A total of 1.8% of hospital admissions for the years 2005 through 2011 were for adult patients with a SSSI primary diagnosis. SSSI-related hospital admissions significantly changed during the study period (P < .001 for trend) ranging from 1.6% (in 2005) to 2.0% (in 2011). Mean hospital length of stay (LOS) decreased from 5.4 days in the year 2005 to 5.0 days in the year 2011 (overall change, P < .001) with no change in hospital costs. Patients with postoperative wound infections had the longest hospital stays (adjusted mean, 5.81 days; 95% confidence interval (CI), 5.80-5.83) and highest total costs (adjusted mean, $9388; 95% CI, $9366-$9410). Year of hospital admission was strongly associated with mortality; infection type, all patient refined diagnosis related group severity of illness level, and LOS were strongly associated with hospital costs. Hospital admissions for adult patients in the United States with a SSSI primary diagnosis continue to increase. Decreasing hospital inpatient LOS and mortality rate may be due to improved early treatment. Future research should focus on identifying alternative treatment processes for patients with SSSI that could shift management from inpatient to outpatient treatment settings.

SMAD4 is an essential mediator in the transforming growth factor-β pathway. Sporadic mutations of SMAD4 are present in 2.1-20.0% of colorectal cancers (CRCs) but data are limited. In this study, we aimed to evaluate clinicopathologic characteristics, prognosis, and clinical outcome associated with this mutation in CRC cases. Data for patients with metastatic or unresectable CRC who underwent genotyping for SMAD4 mutation and received treatment at The University of Texas MD Anderson Cancer Center from 2000 to 2014 were reviewed. Their tumors were sequenced using a hotspot panel predicted to cover 80% of the reported SMAD4 mutations, and further targeted resequencing that included full-length SMAD4 was performed on mutated tumors using a HiSeq sequencing system. Using The Cancer Genome Atlas data on CRC, the characteristics of SMAD4 and transforming growth factor-β pathway mutations were evaluated according to different consensus molecular subtypes of CRC. Among 734 patients with CRC, 90 (12%) had SMAD4 mutations according to hotspot testing. SMAD4 mutation was associated with colon cancer more so than with rectal cancer (odds ratio 2.85; p<0.001), female sex (odds ratio 1.71; p = 0.02), and shorter overall survival than in wild-type SMAD4 cases (median, 29 months versus 56 months; hazard ratio 2.08; p<0.001 [log-rank test]). SMAD4 mutation was not associated with age, stage at presentation, colonic location, distant metastasis, or tumor grade. A subset of patients with metastatic CRC (n = 44) wild-type for KRAS, NRAS, and BRAF who received anti-epidermal growth factor receptor therapy with mutated SMAD4 (n = 13) had shorter progression-free survival duration than did patients wild-type for SMAD4 (n = 31) (median, 111 days versus 180 days; p = 0.003 [log-rank test]). Full-length sequencing confirmed that missense mutations at R361 and P356 in the MH2 domain were the most common SMAD4 alterations. In The Cancer Genome Atlas data, SMAD4 mutation frequently occurred with KRAS, NRAS, and BRAF mutations and was more common in patients with the consensus molecular subtype 3 of CRC than in those with the other 3 subtypes. This is one of the largest retrospective studies to date characterizing SMAD4 mutations in CRC patients and demonstrates the prognostic role and lack of response of CRC to anti-epidermal growth factor receptor therapy. Further studies are required to validate these findings and the role of SMAD4 mutation in CRC.

Background/objective Recessive dystrophic epidermolysis bullosa (RDEB) is a genetic collagen disorder characterized by skin fragility leading to blistering, wounds, and scarring. There are currently no approved curative therapies. The objective of this manuscript is to provide a comprehensive literature review of the disease burden caused by RDEB. Methods A systematic literature review was conducted in MEDLINE and Embase in accordance with PRISMA guidelines. Observational and interventional studies on the economic, clinical, or humanistic burden of RDEB were included. Results Sixty-five studies were included in the review. Patients had considerable wound burden, with 60% reporting wounds covering more than 30% of their body. Increases in pain and itch were seen with larger wound size. Chronic wounds were larger and more painful than recurrent wounds. Commonly reported symptoms and complications included lesions and blistering, anemia, nail dystrophy and loss, milia, infections, musculoskeletal contractures, strictures or stenoses, constipation, malnutrition/nutritional problems, pseudosyndactyly, ocular manifestations, and dental caries. Many patients underwent esophageal dilation (29–74%; median dilations, 2–6) and gastrostomy tube placement (8–58%). In the severely affected population, risk of squamous cell carcinoma (SCC) was 76% and mortality from SCC reached 84% by age 40. Patients with RDEB experienced worsened quality of life (QOL), decreased functioning and social activities, and increased pain and itch when compared to other EB subtypes, other skin diseases, and the general population. Families of patients reported experiencing high rates of burden including financial burden (50–54%) and negative impact on private life (79%). Direct medical costs were high, though reported in few studies; annual payer-borne total medical costs in Ireland were $84,534 and annual patient-borne medical costs in Korea were $7392. Estimated annual US costs for wound dressings ranged from $4000 to $245,000. Patients spent considerable time changing dressings: often daily (13–54% of patients) with up to three hours per change (15–40%). Conclusion Patients with RDEB and their families/caregivers experience significant economic, humanistic, and clinical burden. Further research is needed to better understand the costs of disease, how the burden of disease changes over the patient lifetime and to better characterize QOL impact, and how RDEB compares with other chronic, debilitating disorders.

The objective of the study was to determine if using the hypothermia-detecting bracelet (named BEMPU) improves the duration of Kangaroo Mother Care (KMC) at home by one hour. This parallel-group randomized controlled trial was conducted at a step-down nursery of a teaching hospital. Neonates between 1000 and 2000 g were randomized to BEMPU and control groups at the time of discharge. BEMPU was applied at the wrist of each newborn in the BEMPU (intervention) group. Parents were advised to keep the BEMPU in place till 4 weeks post-discharge. The BEMPU generates a beep sound as an alarm when a newborn's temperature drops below 36.5 °C. Parents in both groups were trained to provide KMC at home. Parents in the BEMPU group received the \"KMC chart\" and \"BEMPU beep chart,\" while the control group received the \"KMC chart\" only. In the \"KMC chart,\" parents entered information about KMC hours on a real-time basis, and in the \"BEMPU beep chart,\" they entered information about alarm beeps from BEMPU on a real-time basis till 4 weeks post-discharge. Independent samples t-test was used to compare mean KMC hours between the two groups. A total of 128 neonates participated in the study (64 in BEMPU and 64 in Control groups). The mean(SD) gestational age for the BEMPU group was 34.04(2.84) weeks vs 34.75(2.70) weeks for the control group. In BEMPU group, mean(SD) daily time spent doing KMC was significantly higher in 1st week [4.78(2.93) vs. 3.22(2.44) h, p  = 0.003], in 2nd week [4.52(3.43) vs. 2.84(2.95) h, p  = 0.008], in 3rd week [4.23(3.71) vs. 2.30(2.70) h, p  = 0.003], in 4th week [3.72(3.30) vs. 1.95(2.65) h, p  = 0.003] as compared to control group. BEMPU improved the daily duration of KMC hours at home compared to the control group over four weeks. Clinical Trial Registration : This trial is registered at Clinical Trials Registry India with registration number: CTRI/2018/08/015154 and accessible at http://ctri.nic.in/Clinicaltrials/pdf_generate.php?trialid=27600&EncHid=&modid=&compid=%27,%2727600det%27 Registered on 01/08/2018.

PurposeClinician–patient language concordance improves patient outcomes in non-intensive care unit (ICU) settings. We sought to assess the association of ICU nurse–patient language concordance with delirium-related outcomes.MethodsWe conducted a retrospective cohort study of adult English- or Spanish-speaking mechanically ventilated ICU patients admitted to ICUs at the University of Miami Hospital and Clinics (January 2021–September 2022). Our primary exposure was nurse–patient language concordance on each shift. We used mixed-effects multivariable regression to evaluate the association of language concordance with the primary outcome of restraint use, and secondary outcomes of agitation and identification of delirium, during each shift (with patient as a random effect).ResultsOur cohort included 4326 shifts (3380 [78.1%] with language concordance) from 548 patients and 157 nurses. Spanish language was preferred by 269 (49.1%) of patients. English-speaking patients tended to be younger (65 [53, 75] vs 73 [61, 83], p < 0.001) and of non-Hispanic ethnicity (55.5% vs 7.1%, p < 0.001). English-speakers had restraints ordered on fewer of their included shifts (0 [0, 3] vs 1 [0, 3], p = 0.005). After adjustment, the odds of restraint use on shifts with language concordance was significantly lower (odds ratio [OR, 95% confidence interval [CI]]: 0.50 [0.39–0.63], p < 0.001). Agitation (18.6% vs 25.2%; OR [95% CI]: 0.71 [0.55–0.92], p = 0.009) and delirium identification (34.5% vs 41.3%; OR [95% CI]: 0.54 [0.34–0.88], p = 0.014) were also less common.ConclusionsWe identified a twofold reduction in the odds of restraint use among mechanically ventilated patients for language concordant nurse–patient dyads. Ensuring nurse–patient language concordance may improve ICU delirium, agitation, and restraint use.