Clinical guidelines exist to promote antibiotic stewardship, particularly in ambulatory care settings such as the emergency department (ED). However, there is limited evidence on prescribing practice for persons with spinal cord injury and disorder (SCI/D). The goal of this study was to assess trends in antibiotic prescribing in the ED setting for persons with SCI/D.
A retrospective dynamic cohort study design.
ED visits that did not result in same day hospitalization over 6 years (fiscal year (FY) 2002-FY2007) in Department of Veterans Affairs (VA) facilities
Veterans with SCI/D.
VA clinical and administrative databases were used to identify the cohort and to obtain demographics, diagnoses, and medications. The rate of antibiotic prescribing for ED visits was defined as the number of antibiotics/total ED visits.
Veterans with SCI/D had 21 934 ED visits and 5887 antibiotics prescribed over the study period (rate of 268.4 prescriptions/1000 visits). The antibiotic prescribing rate increased from 238.8/1000 visits in FY2002 to 310.8/1000 visits in FY2007 (P < 0.0001). This increase in the rate of prescribing was seen across all patient demographics and factors assessed.
Although clinical guidelines for judicious use of antibiotics in persons with SCI/D have been disseminated to providers, antibiotic prescribing in an ED setting is high and continuing to rise in this population.
Physician's practice patterns; Spinal cord injuries; Antibiotic prescribing patterns; Antibiotic resistance; Veterans; Clinical guidelines
Background. Microbial translocation has been implicated in the pathogenesis of liver fibrosis and cirrhosis. We sought to determine whether markers of microbial translocation are associated with liver disease progression during coinfection with human immunodeficiency virus (HIV) and hepatitis C virus (HCV).
Methods. We measured serial plasma lipopolysaccharide (LPS), endotoxin core antibody, intestinal fatty acid–binding protein (I-FABP), soluble CD14 (sCD14), interleukin 6 (IL-6), interleukin 10, and tumor necrosis factor α (TNF-α) levels over a 5-year period in 44 HIV/HCV-coinfected women, 21 of whom experienced liver disease progression and 23 were nonprogressors.
Results. While LPS levels did not differ significantly over time between progressors and nonprogressors (P = .60), progressors had significantly higher plasma levels of sCD14, a marker of monocyte activation by LPS, at the first time point measured (P = .03) and throughout the study period (P = .001); progressors also had higher IL-6 and I-FABP levels over the 5-year study period (P = .02 and .03, respectively). The associations between progression and sCD14, I-FABP, and IL-6 levels were unchanged in models controlling for HIV RNA and CD4+ T-cell count.
Conclusions. Although LPS levels did not differ between liver disease progressors and nonprogressors, the association of sCD14, I-FABP, and IL-6 levels with liver disease progression suggests that impairment of gut epithelial integrity and consequent microbial translocation may play a role in the complex interaction of HIV and HCV pathogenesis.
HIV; hepatitis C; microbial translocation; fibrosis; liver disease progression; soluble CD14
Methicillin-resistant Staphylococcus aureus (MRSA) is a frequent cause of healthcare-associated infection. Individuals with spinal cord injuries and disorders (SCI/D) are at high risk of MRSA colonization and infection. The Department of Veterans Affairs (VA) released guidelines to prevent the spread of MRSA in Veterans with SCI/D; however, available patient educational materials did not address the unique issues for this population.
To assess perceptions of SCI/D providers and Veterans with SCI/D regarding MRSA and their educational needs about MRSA prevention, with an ultimate goal of developing patient educational materials that address the issues unique to SCI/D.
Purposive samples of SCI/D providers (six groups) and Veterans with SCI/D (one group) at two VA facilities participated in 60–90-minute focus group sessions. Qualitative data were analyzed using latent content and constant comparative techniques to identify focal themes.
Thirty-three providers (physicians and nurses working in inpatient, outpatient, and homecare settings) and eight Veterans participated.
Three overarching themes emerged from the analysis: knowledge about MRSA, hand hygiene, and barriers to educating Veterans with SCI/D.
SCI/D providers and Veterans with SCI/D identified gaps in general MRSA knowledge, gaps in knowledge of good hand hygiene practices and of required frequency of hand hygiene, and barriers to educating Veterans with SCI/D during inpatient stays. Future educational materials and strategies should address these gaps.
Spinal cord injuries; Veterans; Infectious disease; Paraplegia; Tetraplegia; Hand hygiene; Staphylococcus aureus; Methicillin resistant; Patient education; Prevention
To assess the impact of knowledge of cervical cancer biology and prevention as well as noncognitive measures on compliance with colposcopy referral in a high risk population.
Participants in a U.S. cohort of women with human immunodeficiency virus (HIV) and at risk comparison women completed behavior questionnaires and instruments measuring knowledge of cervical cancer prevention, depressive symptoms, trust in doctors, and perceived stress. Examinations including Pap tests also were conducted. Associations with compliance with resulting indicated colposcopy were assessed in multivariable models.
Of 326 women with indicated colposcopy, 222 (68%) were compliant with colposcopy referral and 104 (32%) noncompliant. In multivariable analysis, better colposcopy compliance was associated with less education (O.R. for compliance 2.24, 95% C.I. 1.12–4.51 vs more than high school), prior abnormal Pap (O.R. per prior abnormal Pap 1.08 95% C.I. 1.01–1.15), study site (O.R. for site with best vs worst compliance 16.1, 95% C.I. 2.91–88.6), and higher stress (O.R. for Perceived Stress Scale-10 score >16 vs lower 3.25, 95% C.I. 1.45–7.26).
Noncognitive factors and how sites manage abnormal Pap testing affect colposcopy compliance. Educational interventions alone are unlikely to improve colposcopy compliance in similar high-risk populations.
HPV; cervical cancer prevention; Pap test; health education; perceived stress; HIV in women
To estimate the association between vitamin D deficiency and bacterial vaginosis (BV) among nonpregnant HIV-infected and uninfected women.
In a substudy of the Women's Interagency HIV Study, including women from Chicago and New York, the association between BV and vitamin D deficiency, demographics, and disease characteristics was tested using generalized estimating equations. Deficiency was defined as <20 ng/mL 25 (OH) vitamin D and insufficiency as >20 and ≤30 ng/mL. BV was defined by the Amsel criteria.
Among 602 observations of nonpregnant women (480 HIV infected and 122 uninfected), BV was found in 19%. Vitamin D deficiency was found in 59.4%, and insufficiency was found in 24.4%. In multivariable analysis, black race was the most significant predictor of BV (adjusted odds ratio [AOR] 5.90, (95% confidence interval [CI] 2.52-13.8). Vitamin D deficiency was independently associated with BV among HIV-infected women (AOR 3.12, 95% CI 1.16-8.38) but not among HIV-uninfected women. There was a negative linear correlation between vitamin D concentration and prevalence of BV in HIV-infected women (r=−0.15, p=0.001).
Vitamin D deficiency was very common in this cohort and significantly associated with BV among HIV-infected women. These preliminary findings suggest that further epidemiologic and mechanistic exploration of the relationship between vitamin D and BV in HIV-infected women is warranted.
Pneumonia is a leading cause of death in persons with spinal cord injuries and disorders (SCI/D), but little is known about guideline-based management for this disease in persons with SCI/D.
The goal of this study was to describe guideline-based medical care for community-acquired pneumonia (CAP) in veterans with SCI/D. Methods: A retrospective medical record review was conducted at 7 Department of Veterans Affairs (VA) medical centers where veterans with SCI/D and CAP between 2005 and 2008 were included. Outcomes assessed were receipt of blood or sputum culture, antibiotic timeliness, appropriateness of empiric antibiotic treatment, and vaccination.
In 70 patients, 77 CAP episodes occurred and 83.1% were treated in the inpatient setting. The average age was 70.0 years and 64.9% had tetraplegia. Sputum culture was completed in 24.7% and blood culture in 59.7% of cases. Of inpatients, 79.7% had antibiotic treatment within 8 hours and 45.1% received guideline-recommended empirical antibiotics. More than 90% of inpatients received antibiotic treatment within 3 days of presentation and 78.1% received recommended treatment. The rates of pneumococcal pneumonia (89.9%) and influenza (79.7%) vaccinations were high in CAP cases.
Diagnostic testing and early guideline-recommended treatment is variable in veterans with SCI/D and CAP. However vaccination against influenza and pneumococcal pneumonia is high. Specific guidelines for management of CAP in SCI/D patients may be needed, which reflect the unique risk factors and needs of this population. These data can be used as a benchmark for improvements in care processes for treating and managing CAP in persons with SCI/D.
antibiotics; disease management; pneumonia; practice guideline; spinal cord injuries
Few empirical studies have examined the disaster preparedness and response practices of individuals with spinal cord injuries and/or disorders (SCI/D) and the healthcare providers who serve them. This study was conducted to understand the experiences of Veterans Health Administration (VHA) providers and Veterans with SCI/D in recent natural disasters, and to identify lessons learned for disaster preparedness and response in the context of SCI/D.
Semi-structured interviews were conducted with providers and Veterans recruited through seven VHA facilities that had sustained a disaster since 2003. Audio recordings of the interviews were transcribed; transcripts were analyzed using constant comparative techniques.
Forty participants completed an interview, including 21 VHA SCI/D providers and 19 Veterans with SCI/D. Disasters experienced by participants were weather related. While many Veterans were evacuated or admitted to nearby VHA facilities, others chose to stay in their communities. All facilities had formal disaster plans and engaged in related training; however, participants explained that many aspects of a response take shape ‘in the moment,’ and must address both provider and Veteran needs. Dispersion of resources hindered well-coordinated care, but effective communication, teamwork, advanced warnings, and VHA's electronic medical record facilitated efforts.
Even in the case of thorough planning, Veterans with SCI/D and their healthcare providers are faced with pressing needs during disasters, and identifying strategies to coordinate care is critical. The lessons learned are intended to inform the efforts of healthcare providers who may be involved in the care of individuals with SCI/D in future disasters.
Disasters; Disaster planning; Veterans; Health personnel; Spinal cord injuries; Qualitative research
Persons with spinal cord injury or disorder (SCI/D) are at increased risk for antibiotic resistance because of recurrent infections and subsequent use of antibiotics. However, there are no studies focused on providers who care for these patients and their perceptions regarding antibiotic use and resistance.
To characterize SCI/D provider behavior and attitudes about antibiotic prescribing and resistance.
Anonymous internet-based, cross-sectional survey.
A total of 314 SCI/D clinicians who prescribe antibiotics (physicians, physician assistants, and nurse practitioners).
A total of 118 providers responded (37.6% response rate) including 80 physicians, 20 nurse practitioners, and 18 physician assistants. The majority of respondents agreed with statements regarding the societal impact of antibiotic resistance; only 17.8% agreed that they prescribed antibiotics more than they should, but 61.0% agreed that patient demand was a major reason for prescribing unnecessary antibiotics. The most frequent problematic organisms reported were: methicillin-resistant Staphylococcus aureus (83.1%), multidrug-resistant Pseudomonas (61.0%), and Clostridium difficile (57.6%). The most frequent antibiotics selected for outpatient treatment of community-acquired pneumonia treatment, based on a clinical scenario were azithromycin (36.4%) and respiratory fluoroquinolones (22.9%).
These data show that the respondents are aware of and concerned with the problem of antibiotic resistance in their practice. Clinician respondents also endorsed the need to improve their own knowledge and that of their colleagues regarding appropriate antibiotic prescribing. These findings suggest that interventions should focus on provider education, particularly regarding appropriate antibiotic prescribing.
Spinal cord injuries; Infectious disease; Pneumonia; Drug resistance; Anti-bacterial agents; Azithromycin; Amoxicillin/clavulanate; Moxifloxacin; Antibiotic prescribing patterns; Attitude of health personnel
Little is known about those veterans with spinal cord injuries and disorders (SCI/D) who smoke cigarettes. This study identified the factors associated with smoking in this population, motivations for smoking, and the readiness for smoking cessation. Current practices for the delivery of evidence-based tobacco cessation were also examined.
Methods included surveys of veterans with SCI/D, medical record reviews of current smokers, and telephone interviews with SCI/D providers.
Six Veterans Health Administration facilities with SCI centers and one SCI clinic.
Survey data were analyzed for 1210 veterans, 256 medical records were reviewed, and 15 providers served as key informants.
Veterans self-reported smoking status, quit attempts, methods and care received, motivation for smoking, and health care conditions. Medical record review and informant interviews examined the tobacco cessation care provided.
Whereas 22% of the respondents were current smokers; 51% were past smokers. Current smokers more often reported respiratory illnesses and/or symptoms, alcohol use, pain, and depression than past or never smokers, and approximately half made quit attempts in the past year. Smokers received referral to counseling (57%) and/or prescription for medication/nicotine replacement (23%). Key informants identified difficulty of providing follow-up and patients' unwillingness to consider quitting as barriers.
Veterans with SCI/D who smoke also had other health problems. Providers offer counseling and medication, but often have difficulty following patients to arrange/provide support. Identifying other support methods such as telehealth, considering the use of combination cessation therapies, and addressing other health concerns (e.g. depression) may affect tobacco cessation in this population.
Tobacco cessation; Spinal cord injury; Evidence-based care
To estimate changes in high risk women’s knowledge of cervical cancer prevention, human papillomavirus (HPV), and HPV vaccination since introduction and marketing of HPV vaccines.
At study visits in 2006 and 2008, women with the human immunodeficiency virus (HIV) and at-risk comparison women in a multicenter U.S. cohort study completed 44-item self-report questionnaires exploring their knowledge of cervical cancer prevention, HPV, and HPV vaccination. Results from 2006 were compared to those obtained in 2008. Knowledge scores were correlated with demographic variables, measures of education and attention, and medical factors. Significant associations were assessed in multivariable models.
HIV-seropositive women had higher knowledge scores than seronegative women at baseline (13.2 +/− 5.7 vs 11.8 +/− 6.0, P = 0.0002) and follow-up (14.1 +/− 5.3 vs 13.2 +/− 5.5, P = 0.01), but the change in scores was similar (0.9 +/− 5.3 vs 1.5 +/− 5.5, P = 0.13). Knowledge that cervical cancer is caused by a virus rose significantly (P = 0.005), but only to 24%. Belief that cervical cancer is preventable only rose from 52% to 55% (P = 0.04), but more than 90% of women in both periods believed regular Pap testing was important. In ANCOVA models, higher baseline score, younger age, higher education level, higher income, and former- as opposed to never-drug users, but not HIV status, were associated with improved knowledge.
High-risk women’s understanding of cervical cancer and HPV has improved, but gaps remain. Improvement has been weakest for less-educated and lower-income women.
To assess knowledge of and attitudes towards human papillomavirus (HPV), Pap testing, and the HPV vaccine.
In a multicenter U.S. cohort study, women with the human immunodeficiency virus (HIV) and at-risk comparison women completed 44-item standardized self-report questionnaires exploring their knowledge of cervical cancer prevention, HPV, and HPV vaccination. Results were correlated with demographic variables, measures of education and attention, and medical factors. Data were clustered using principal component analysis. Significant associations were assessed in multivariable models.
Among 1588 women, HIV seropositive women better understood facts about cervical cancer prevention and HPV than seronegative women, but both had substantial knowledge deficits. Almost all women considered Pap testing important, although 53% of HIV seropositive and 48% of seronegative women considered cervical cancer not preventable (P=0.21). Only 44% of HIV seropositive women knew Paps assess the cervix, versus 42% of HIV seronegative women (P=0.57). Both groups understood that HPV causes genital warts and cervical cancer (67% of HIV seropositive vs. 55% of seronegative women, P=0.002). About half of both groups considered HPV vaccination extremely important for cervical cancer prevention. HIV seronegative women were more likely to report learning of HPV vaccination through advertising than from clinicians (81% vs. 64%, P<0.0001).
High risk women need effective education about cervical cancer prevention, HPV, and HPV vaccination.
HPV; Cervical cancer prevention; Pap test; Health education; HIV in women
Isolated antibody to hepatitis B core antigen (anti-HBc) is a common serologic finding in persons infected with human immunodeficiency virus (HIV), but the outcome and clinical significance are uncertain.
We performed repeated hepatitis B virus (HBV) serologic tests on women who participated in the Women’s Interagency HIV Study and who had isolated anti-HBc at study entry.
Repeated serologic tests were performed for 322 women (282 HIV-infected and 40 HIV-uninfected) at a median of 7.5 years after study entry. Seventy-one percent of women retained isolated anti-HBc serologic status, 20% acquired antibody to hepatitis B surface antigen (anti-HBs), and 2% acquired hepatitis B surface antigen (HBsAg). In unadjusted analysis, increasing age, injection drug use, and hepatitis C viremia were negatively associated with acquisition of anti-HBs. For HIV-infected women, predictors of acquisition of anti-HBs were an increase in CD4 cell count and the use of highly active antiretroviral therapy (HAART). Receipt of drugs with activity against HBV and self-reported HBV vaccination did not predict anti-HBs acquisition. In the multivariable regression model, HAART use remained a significant predictor of anti-HBs acquisition, whereas women with hepatitis C viremia were more likely to retain isolated anti-HBc serologic status.
Isolated anti-HBc status remained stable over time for the majority of women, especially women with chronic hepatitis C virus infection. Development of anti-HBs was predicted by HAART use and an increase in CD4 cell count. We conclude that a proportion of HIV-infected women with isolated anti-HBc have prior natural HBV infection with anti-HBs that is at an undetectable level because of immune dysfunction. Isolated anti-HBc in the presence of chronic hepatitis C virus infection may be attributable to a different phenomenon, such as dysfunctional antibody production.
Respiratory complications are a major cause of illness and death in persons with spinal cord injuries and dysfunction (SCI&Ds). The objectives of this study were to examine rates of outpatient visits over 5 years for acute respiratory tract infections (ARIs), including pneumonia and influenza (P&I), lower respiratory tract infections (LRIs), and upper respiratory tract infections (URIs), in veterans with SCI&Ds and to determine whether individual characteristics were associated with the number of annual visits for each type of ARI.
This was a longitudinal (fiscal years 1998–2002) study of ARI visits at the Veterans Health Administration (VA) in 18,693 veterans with SCI&Ds. To examine the associations between time, patient characteristics, and annual number of ARI visits, we used random effect negative binomial models.
Veterans with SCI&Ds had a total of 11,113 ARI visits over the 5-year period. There was a slightly decreasing trend for LRI visits over time (P < 0.01) but no significant change for other ARIs over time. There were 30 to 35 pneumonia visits and 21 to 30 acute bronchitis visits per 1,000 SCI&D veterans per year. Older veterans were more likely than younger to have P&I visits and less likely to have URI visits (P < 0.01). Veterans with paraplegia had fewer P&I visits than subjects with tetraplegia (IRR = 0.58; CI = 0.51–0.67).
Visit rates for ARIs are stable for veterans with SCI&Ds. Identifying risk factors associated with ARI visits is an important first step to improve prevention and treatment of ARIs and to improve the health of veterans with SCI&Ds.
Spinal cord injuries; Veterans; Acute respiratory tract infection; Pneumonia; Influenza; Bronchitis; Paraplegia; Tetraplegia
To assess patient and provider behaviors regarding influenza vaccination, diagnosis, and testing strategies and the availability of influenza vaccine during the 2004–2005 nationwide influenza vaccine shortage.
Multisite, anonymous, cross-sectional surveys of patients and providers and qualitative interviews after the 2004–2005 influenza season.
Department of Veterans Affairs (VA) health care facilities with spinal cord injury centers or clinics.
Stratified random sample of 3,958 veterans with spinal cord injuries and disorders (SCI&D; 31 % response rate), 177 providers who treat persons with SCI&D, and 17 key informants.
Most patient respondents (96.1%) reported awareness of a vaccine shortage (n = 938). When asked whether the shortage affected their ability to get the vaccine, 64.8% said they had no problem, whereas 12.1% reported an inability to get the vaccine. The vaccination rate was 71.8%; most veterans received the vaccine early (October–November) at the VA, and vaccination rates increased with age (P < 0.0001). Although vaccine shortages were reported by 47.5% of provider survey respondents (n = 177), most reported that the vaccine shortage did not affect availability of vaccine for patients with SCI&D. Few clinicians conducted diagnostic tests for influenza more often than in past years (4.9%). Although providers reported shortages at 12 centers (n = 23), patients with SCI&D had priority at 11 of 12 centers.
Most patients were aware of the vaccine shortage, and the vaccination rate remained high and comparable with previous years. VA providers and facilities targeted SCI&D as a high-risk group and prioritized use of the limited vaccine supply for them.
Influenza; Vaccination; Health care workers; Spinal cord injuries; Prevention
To increase the percentage of veterans with spinal cord injuries and disorders (SCI&D) who receive annual influenza vaccinations.
A repeated measures quality improvement project using several integrated evidence-based interventions.
23 Veterans Affairs (VA) SCI Centers.
Veterans with SCI&D average age = 57.3 years (range 21–102 y).
Patient reminder letters and education; provider reminders and posters; computerized clinical reminders for vaccination targeted to SCI&D; standing orders. Main outcome measures: Patient self-reported vaccination status.
Baseline vaccination rate was 33% in fiscal year (FY) 2001. The percentage of veterans with SCI&D who reported receiving vaccinations increased from 62.5% in year 1 (FY2002) to 67.4% in FY2003 (P = 0.004); for individuals younger than 50 years of age, rates increased from 50% to 54%. Predictors of vaccination were age 65 years of age or older, VA health care visit in past year, nonsmoker, believing vaccination is important, having a health condition that may contribute to respiratory complications, and self-reported influenza in prior year.
Vaccination rates were higher than baseline and higher than reported for other high-risk groups. Interventions that incorporate system-wide approaches plus patient and provider education and reminders were moderately effective in increasing vaccination rates. Targeting younger persons, smokers, and those who do not use VA care may further improve rates.
Vaccination; Spinal cord injuries; Influenza; Prevention; Veterans; Respiratory infections
Monitoring vaccination activity requires regular access to information about patient vaccination status. This report describes our experience using multiple Department of Veterans Affairs (VA) data sources to determine availability and completeness of vaccination information for veterans with spinal cord injuries and disorders (SCI&D). Administrative and clinical databases were limited to coding vaccine administration, undercounted vaccinations, and were unable to account for whether the vaccine was offered and the reasons for nonreceipt. Medical record review provided more detail but was labor intensive and costly. Patient surveys provided the richest information but were costly, time-consuming, and based on a sample of patients. Agreement was poor between data sources. This report suggests that while VA is well positioned to use national databases for clinical care decisions and to inform policy, vaccination data were incomplete. Electronic records must include data that are consistently entered and validated before they can be useful for care management and decision making.