Daily Sepsis Research Analysis

IMPORTANCE: The ABATE Infection trial investigated the effects of universal bacterial decolonization with chlorhexidine for patients in non-intensive care unit settings to reduce hospital-onset bacteremia and fungemia (HOB) events. Among patients with medical devices (central venous catheters, midline catheters, and lumbar drains), universal decolonization (UD) resulted in a significant and meaningful reduction in bacteremia compared with the standard of care (SOC), but cost-effectiveness is unclear. OBJECTIVE: To examine the cost-effectiveness of universal and targeted bathing strategies compared with SOC in general medical and surgical units. DESIGN, SETTING, AND PARTICIPANTS: A decision analytic model was constructed from June 1, 2021, to May 31, 2024, to simulate the frequency of HOB and costs under 3 strategies: SOC, UD, and targeted decolonization (TD). The model included a simulated cohort representative of the cluster-randomized ABATE Infection trial, which involved more than 500 000 participants across the US. MAIN OUTCOMES AND MEASURES: In TD, decolonization was administered for patients with medical devices only. Upstream costs of bathing and downstream costs of HOB, under payer and hospital perspectives were included. Parameters were informed by the ABATE Infection Trial and additional literature. Willingness-to-pay per HOB prevented was adopted as $25 000 for payers and $10 000 for hospitals. Sensitivity analyses were tailored to populations with different characteristics. RESULTS: The simulated cohort, based on the population from the ABATE trial, included 529 000 adult admissions with a mean (SD) age of 63 (18) years, 54% female, and 13% with a central venous catheter, midline catheter, or lumbar drain. In the base case, the SOC was least effective and most costly. Targeted decolonization was least costly and UD resulted in the fewest HOB events. Targeted decolonization was the cost-effective strategy from payer and hospital perspectives. Compared with TD, UD had an incremental cost-effectiveness ratio of $119 700 per HOB averted from the payer perspective, and $126 600 per HOB averted from the hospital perspective. Depending on willingness-to-pay, UD may be preferred in scenarios with a higher proportion of patients with medical devices, greater reductions in HOB from decolonizing in those with devices, and lower adherence under TD. CONCLUSIONS AND RELEVANCE: In this decision analytic model studying universal and targeted bathing, TD was cost-effective under a broad range of scenarios for both hospital system and payer decision-makers. Universal decolonization was cost-effective in some scenarios, such as in specific units where many patients have medical devices or if it were difficult to implement a targeted approach.

Sepsis occurs predominantly in low-middle-income countries. Sub-optimal triage contributes to poor early case recognition and outcomes from sepsis. Improved recognition and quality of care can lead to improved outcomes. We evaluated the impact of Smart Triage using improved time to intravenous antimicrobial administration in a multisite interventional study. Smart Triage, a digital platform with a risk score and clinical dashboard, was implemented (with control sites) in Kenya (February 2021-December 2022) and Uganda (April 2020-April 2022). Children presenting to the outpatient departments with an acute illness were enrolled. A controlled interrupted time series was used to assess the effect on time from arrival at the facility to intravenous antimicrobial administration. Secondary analyses included antimicrobial use, admission rates and mortality (NCT04304235). During the baseline period, the time to antimicrobials decreased significantly in Kenya (132 and 58 minutes) at control and intervention sites. In Uganda, the time to antimicrobials marginally decreased (3 minutes) at the intervention site. Then, during the implementation period in Kenya, the time to antimicrobials at the intervention site decreased by 98 min (57%, 95% CI 81-114) but increased by 49 min (21%, 95% CI: 23-76) at the control site. In Uganda, the time to antimicrobials initially decreased but was not sustained and there was no significant difference between intervention and control sites. At both intervention sites, there was a significant reduction in antimicrobial utilization of 47% (Kenya) and 33% (Uganda) compared to baseline. There was a reduction in admission rates of 47% (Kenya) and 33% (Uganda) compared to baseline. Mortality reduced by 25% (Kenya) and 75% (Uganda) compared to the baseline period. We showed significant improvements in time to intravenous antibiotics in Kenya but not Uganda, likely due to COVID-19, a short study period and resource constraints. The reduced antimicrobial use and admission and mortality rates are remarkable and welcome benefits. The admission and mortality rates should be interpreted cautiously as these were secondary outcomes. This study underlines the difficulty of implementing technologies and sustaining quality improvement in health systems.

INTRODUCTION: Antibiotic overuse and subsequent antibiotic resistance lead to worse infection outcomes in cirrhosis. Secondary spontaneous bacterial peritonitis prophylaxis (SecSBBPr) is associated with higher SBP recurrence, but impact on non-SBP infections is unclear. METHODS: We studied patients with cirrhosis and SBP who were given SecSBPPr or not between 2009 and 2019 in 2 complementary national cohorts (Veterans Affairs Corporate Data Warehouse [VA-CDW] and non-VA TriNetX). Development of total non-SBP infections and specifically urinary tract infections (UTIs), bacteremia, pneumonia, and C. difficile using validated codes over 2 years was compared between those on SecSBPPr vs not. Multivariable regression for non-SBP infections was performed. RESULTS: VA-CDW: Of 4,673 veterans with index SBP, 2,539 (54.3%) were started on SecSBPPr. In total, 1,406 (30.1%) developed non-SBP infections (13.5% UTI, 12.4% pneumonia, 8.5% bacteremia, and 6.8% C. difficile ). On multivariable regression, SecSBPPr was significantly associated with any non-SBP infection (odds ratio [OR] 1.26, 95% confidence interval [CI] 1.10-1.44, P < 0.0001) and UTI (OR 1.21, 95% CI 1.01-1.45, P = 0.036). TriNetX: Of 6,708 patients with index SBP, 3,261 (48.6%) were started on SecSBPPr. In total, 1,932 (28.8%) patients developed non-SBP infections (13.4% UTI, 12.9% pneumonia, 8.6% bacteremia, and 5.9% C. difficile ). On multivariable regression, SecSBPPr was significantly associated with any non-SBP infection (OR 1.33, 95% CI 1.12-1.59, P < 0.0001), UTI (OR 1.35, 95% CI 1.07-1.71, P = 0.010), pneumonia (OR 1.35, 95% CI 1.06-1.72, P = 0.017), and bacteremia (OR 1.47, 95% CI 1.10-1.97, P = 0.009). DISCUSSION: In 2 diverse US-based national cohorts of patients with cirrhosis and SBP, use of SecSBPPr was associated with a higher risk of non-SBP infections, especially urinary tract infections.