Browsing by Author "Rennert-May, Elissa"
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- ItemOpen AccessA cost-effectiveness analysis of mupirocin and chlorhexidine gluconate for Staphylococcus aureus decolonization prior to hip and knee arthroplasty in Alberta, Canada compared to standard of care(2019-07-11) Rennert-May, Elissa; Conly, John; Smith, Stephanie; Puloski, Shannon; Henderson, Elizabeth; Au, Flora; Manns, BradenAbstract Background While decolonization of Staphylococcus aureus reduces surgical site infection (SSI) rates following hip and knee arthroplasty, its cost-effectiveness is uncertain. We sought to examine the cost-effectiveness of a decolonization protocol for Staphylococcus aureus prior to hip and knee replacement in Alberta compared to standard care – no decolonization. Methods Decision analytic models and a probabilistic sensitivity analysis were used for a cost-effectiveness analysis, with the effectiveness of decolonization based on a large published pre- and post- intervention trial. The primary outcomes of the models were infections prevented and health care costs. We modelled the cost-effectiveness of decolonization in a hypothetical cohort of adult patients undergoing hip and knee replacement in Alberta, Canada. Information on the incidence of complex surgical site infections (SSIs), as well as the cost of care for patients with and without SSIs was taken from a provincial infection control database, and health administrative data. Results Use of the decolonization bundle was cost saving compared to usual care ($153/person), and resulted in 16 complex Staphylococcus aureus SSIs annually as opposed to 32 (with approximately 8000 hip or knee arthroplasties performed). The probabilistic sensitivity analysis demonstrated that the majority (84%) of the time the decolonization bundle was cost saving. The model was robust to one-way sensitivity analyses conducted within plausible ranges. There were small upfront costs associated with using a decolonization protocol, however, this model demonstrated cost savings over one year. In a Markov model that considered the impact of a decolonization bundle over a lifetime as it pertained to the need for subsequent joint replacements and patient quality of life, the bundle still resulted in cost savings ($161/person). Conclusions Decolonization for Staphylococcus aureus prior to hip and knee replacements resulted in cost savings and fewer SSIs, and should be considered prior to these procedures.
- ItemOpen AccessAntimicrobial resistance (AMR) in COVID-19 patients: a systematic review and meta-analysis (November 2019–June 2021)(2022-03-07) Kariyawasam, Ruwandi M.; Julien, Danielle A.; Jelinski, Dana C.; Larose, Samantha L.; Rennert-May, Elissa; Conly, John M.; Dingle, Tanis C.; Chen, Justin Z.; Tyrrell, Gregory J.; Ronksley, Paul E.; Barkema, Herman W.Abstract Background Pneumonia from SARS-CoV-2 is difficult to distinguish from other viral and bacterial etiologies. Broad-spectrum antimicrobials are frequently prescribed to patients hospitalized with COVID-19 which potentially acts as a catalyst for the development of antimicrobial resistance (AMR). Objectives We conducted a systematic review and meta-analysis during the first 18 months of the pandemic to quantify the prevalence and types of resistant co-infecting organisms in patients with COVID-19 and explore differences across hospital and geographic settings. Methods We searched MEDLINE, Embase, Web of Science (BioSIS), and Scopus from November 1, 2019 to May 28, 2021 to identify relevant articles pertaining to resistant co-infections in patients with laboratory confirmed SARS-CoV-2. Patient- and study-level analyses were conducted. We calculated pooled prevalence estimates of co-infection with resistant bacterial or fungal organisms using random effects models. Stratified meta-analysis by hospital and geographic setting was also performed to elucidate any differences. Results Of 1331 articles identified, 38 met inclusion criteria. A total of 1959 unique isolates were identified with 29% (569) resistant organisms identified. Co-infection with resistant bacterial or fungal organisms ranged from 0.2 to 100% among included studies. Pooled prevalence of co-infection with resistant bacterial and fungal organisms was 24% (95% CI 8–40%; n = 25 studies: I2 = 99%) and 0.3% (95% CI 0.1–0.6%; n = 8 studies: I2 = 78%), respectively. Among multi-drug resistant organisms, methicillin-resistant Staphylococcus aureus, carbapenem-resistant Acinetobacter baumannii, Klebsiella pneumoniae, Pseudomonas aeruginosa and multi-drug resistant Candida auris were most commonly reported. Stratified analyses found higher proportions of AMR outside of Europe and in ICU settings, though these results were not statistically significant. Patient-level analysis demonstrated > 50% (n = 58) mortality, whereby all but 6 patients were infected with a resistant organism. Conclusions During the first 18 months of the pandemic, AMR prevalence was high in COVID-19 patients and varied by hospital and geography although there was substantial heterogeneity. Given the variation in patient populations within these studies, clinical settings, practice patterns, and definitions of AMR, further research is warranted to quantify AMR in COVID-19 patients to improve surveillance programs, infection prevention and control practices and antimicrobial stewardship programs globally.
- ItemEmbargoBarriers and Facilitators to the Implementation of a Decolonization Strategy for Staphylococcus aureus prior to Hip and Knee Arthroplasty in Alberta, Canada: A multi-methods study(2023-05-16) Whelan, Lindsay Jane; Rennert-May, Elissa; Barkema, Herman; Leal, Jenine; Leslie, MylesAlberta recently implemented a decolonization strategy as part of the clinical care pathway prior to hip and knee replacements. The decolonization strategy includes three days of chlorohexidine gluconate (CHG) sponge baths and five days of mupirocin ointment (MO) intranasally twice daily leading up to surgery. Preoperative decolonization prior to hip and knee replacements reduces the incidence of surgical site infections (SSIs), but the effectiveness in Alberta is unknown. For a decolonization strategy to be effective, patients and clinic staff should adhere to the protocol and there should be no negative outcomes. We used multi-methods to assess the barriers and facilitators with a decolonization strategy by assessing patients and clinic staff compliance, and baseline prevalence of antimicrobial resistance (AMR) to topical antibiotics. Using qualitative methods, semi-structured interviews and focus groups were used to understand clinic adherence with decolonization. Knowledge and understanding were central to implementation. When present, knowledge and understanding acted as a facilitator, when absent or inconsistent, it was a barrier to implementation. Using descriptive surveys, we analysed patient compliance with proportions of compliance, differences with compliance in urban versus rural clinics using logistic regression, and reasons for non-compliance with frequency counts. In our analysis, CHG sponges had a greater proportion of compliance compared to MO but not when CHG sponges and MO were used together. Patients in rural clinics had increased odds of compliance with three CHG sponges than urban clinics and males had increased odds of compliance with MO in urban locations. Common reasons for non-compliance included sponges not provided, patient forgot, and surgery date moved. To assess AMR to topical antibiotics, specimens from SSIs following hip or knee arthroplasty were collected (n=81) and 43 specimens were Staphylococcus-positive. Among these specimens, coagulase-negative staphylococci isolates carried resistance genes associated with CHG (n=10) and mupirocin (n=6). Our results indicate that while a decolonization strategy in Alberta has been successfully implemented, it could benefit from improvements with clinic and patient compliance. Furthermore, the prevalence of AMR to topical antibiotics will need to be continuously monitored for changes.
- ItemOpen AccessA Cost-Effectiveness Analysis of a Decolonization Protocol for Staphylococcus aureus Prior to Hip and Knee Arthroplasty in Alberta, Canada(2019-04-30) Rennert-May, Elissa; Manns, Braden J.; Conly, John M.; Smith, Stephanie Wrenn; Puloski, Shannon K. T.; Henderson, Elizabeth Ann; Loeb, MarkThere are over 100,000 knee/hip replacements yearly in Canada. While these procedures improve mobility and quality of life, approximately 1% develop complex surgical site infections (SSIs) after surgery. Detailed costing analysis of these infections, particularly in Canada, is lacking. We assessed incidence and cost of complex SSIs following primary hip/knee arthroplasty in patients across Alberta. We then evaluated the cost-effectiveness of an evidence-based decolonization protocol in patients prior to hip/knee arthroplasty in Alberta, compared with standard care (no decolonization) using decision analysis. Among 24,667 operations, 1.04% developed a complex SSI. The most common causative pathogen was Staphylococcus aureus (38%). Mean first-year costs for the infected and non-infected cohort were CAN $95,321 (IQR49,623 – 120,636) and $19,893 (IQR12,610 – 19,723), respectively. The decolonization protocol was associated with lower risk of complex SSI and cost savings of $153/person. A decolonization protocol should be considered for implementation in Alberta to reduce infections and save costs.
- ItemOpen AccessEconomic evaluations and their use in infection prevention and control: a narrative review(2018-02-27) Rennert-May, Elissa; Conly, John; Leal, Jenine; Smith, Stephanie; Manns, BradenAbstract Background The objective of this review is to provide a comprehensive overview of the different types of economic evaluations that can be utilized by Infection Prevention and Control practitioners with a particular focus on the use of the quality adjusted life year, and its associated challenges. We also highlight existing economic evaluations published within Infection Prevention and Control, research gaps and future directions. Design Narrative Review. Conclusions To date the majority of economic evaluations within Infection Prevention and Control are considered partial economic evaluations. Acknowledging the challenges, which include variable utilities within infection prevention and control, a lack of randomized controlled trials, and difficulty in modelling infectious diseases in general, future economic evaluation studies should strive to be consistent with published guidelines for economic evaluations. This includes the use of quality adjusted life years. Further research is required to estimate utility scores of relevance within Infection Prevention and Control.
- ItemOpen AccessHealthcare utilization and adverse outcomes stratified by sex, age and long-term care residency using the Alberta COVID-19 Analytics and Research Database (ACARD): a population-based descriptive study(2023-05-19) Rennert-May, Elissa; Crocker, Alysha; D’Souza, Adam G.; Zhang, Zuying; Chew, Derek; Beall, Reed; Vickers, David M.; Leal, JenineAbstract Background Understanding the epidemiology of Coronavirus Disease of 2019 (COVID-19) in a local context is valuable for both future pandemic preparedness and potential increases in COVID-19 case volume, particularly due to variant strains. Methods Our work allowed us to complete a population-based study on patients who tested positive for COVID-19 in Alberta from March 1, 2020 to December 15, 2021. We completed a multi-centre, retrospective population-based descriptive study using secondary data sources in Alberta, Canada. We identified all adult patients (≥ 18 years of age) tested and subsequently positive for COVID-19 (including only the first incident case of COVID-19) on a laboratory test. We determined positive COVID-19 tests, gender, age, comorbidities, residency in a long-term care (LTC) facility, time to hospitalization, length of stay (LOS) in hospital, and mortality. Patients were followed for 60 days from a COVID-19 positive test. Results Between March 1, 2020 and December 15, 2021, 255,037 adults were identified with COVID-19 in Alberta. Most confirmed cases occurred among those less than 60 years of age (84.3%); however, most deaths (89.3%) occurred among those older than 60 years. Overall hospitalization rate among those who tested positive was 5.9%. Being a resident of LTC was associated with substantial mortality of 24.6% within 60 days of a positive COVID-19 test. The most common comorbidity among those with COVID-19 was depression. Across all patients 17.3% of males and 18.6% of females had an unplanned ambulatory visit subsequent to their positive COVID-19 test. Conclusions COVID-19 is associated with extensive healthcare utilization. Residents of LTC were substantially impacted during the COVID-19 pandemic with high associated mortality. Further work should be done to better understand the economic burden associated with related healthcare utilization following a COVID-19 infection to inform healthcare system resource allocation, planning, and forecasting.
- ItemOpen AccessProtocol for a parallel economic evaluation of a trial comparing two surgical strategies in severe complicated intra-abdominal sepsis: the COOL-cost study(2020-02-21) Ng-Kamstra, Joshua S; Rennert-May, Elissa; McKee, Jessica; Lundgren, Skyla; Manns, Braden; Kirkpatrick, Andrew WAbstract Background The risk of death in severe complicated intra-abdominal sepsis (SCIAS) remains high despite decades of surgical and antimicrobial research. New management strategies are required to improve outcomes. The Closed Or Open after Laparotomy (COOL) trial investigates an open-abdomen (OA) approach with active negative pressure peritoneal therapy. This therapy is hypothesized to better manage peritoneal bacterial contamination, drain inflammatory ascites, and reduce the risk of intra-abdominal hypertension leading to improved survival and decreased complications. The total costs and cost-effectiveness of this therapy (as compared with standard fascial closure) are unknown. Methods We propose a parallel cost-utility analysis of this intervention to be conducted alongside the 1-year trial, extrapolating beyond that using decision analysis. Using resource use metrics (e.g., length of stay, re-admissions) from patients at all study sites and microcosting data from patients enrolled in Calgary, Alberta, the mean cost difference between treatment arms will be established from a publicly-funded health care payer perspective. Quality of life will be measured at 6 months and 1 year postoperatively with the Euroqol EQ-5D-5 L and SF-36 surveys. A within-trial analysis will establish cost and utility at 1 year, using a bootstrapping approach to provide confidence intervals around an estimated incremental cost-effectiveness ratio. If neither operative strategy is economically dominant, Markov modeling will be used to extrapolate the cost per quality-adjusted life years gained to 2-, 5-, 10-year, and lifetime horizons. Future costs and benefits will be discounted at 1.5% per annum. A cost-effectiveness acceptability curve will be generated using Monte Carlo simulation. If all trial outcomes are similar, the primary analysis will default to a cost-minimization approach. Subgroup analysis will be carried out for patients with and without septic shock at presentation, and for patients whose initial APACHE II scores are > 20 versus ≤ 20. Discussion In addition to an estimate of the clinical effectiveness of an OA approach for SCIAS, an understanding of its cost effectiveness will be required prior to its adoption in any resource-constrained environment. We will estimate this key parameter for use by clinicians and policymakers. Trial Registration ClinicalTrials.gov, NCT03163095, registered May 22, 2017.
- ItemOpen AccessThe economic burden of cardiac implantable electronic device infections in Alberta, Canada: a population-based study using validated administrative data(2023-12-05) Rennert-May, Elissa; Chew, Derek; Cannon, Kristine; Zhang, Zuying; Smith, Stephanie; King, Teagan; Exner, Derek V.; Larios, Oscar E.; Leal, JenineAbstract Background Cardiac implantable electronic devices (CIED) are being inserted with increasing frequency. Severe surgical site infections (SSI) that occur after device implantation substantially impact patient morbidity and mortality and can result in multiple hospital admissions and repeat surgeries. It is important to understand the costs associated with these infections as well as healthcare utilization. Therefore, we conducted a population-based study in the province of Alberta, Canada to understand the economic burden of these infections. Methods A cohort of adult patients in Alberta who had CIEDs inserted or generators replaced between January 1, 2011 and December 31, 2019 was used. A validated algorithm of International Classification of Diseases (ICD) codes to identify complex (deep/organ space) SSIs that occurred within the subsequent year was applied to the cohort. The overall mean 12-month inpatient and outpatient costs for the infection and non-infection groups were assessed. In order to control for variables that may influence costs, propensity score matching was completed and incremental costs between those with and without infection were calculated. As secondary outcomes, number of outpatient visits, hospitalizations and length of stay were assessed. Results There were 26,049 procedures performed during our study period, of which 320 (1.23%) resulted in SSIs. In both unadjusted costs and propensity score matched costs the infection group was associated with increased costs. Overall mean cost was $145,312 in the infection group versus $34,264 in the non-infection group. The incremental difference in those with infection versus those without in the propensity score match was $90,620 (Standard deviation $190,185). Approximately 70% of costs were driven by inpatient hospitalizations. Inpatients hospitalizations, length of stay and outpatient visits were all increased in the infection group. Conclusions CIED infections are associated with increased costs and are a burden to the healthcare system. This highlights a need to recognize increasing SSI rates and implement measures to minimize infection risk. Further studies should endeavor to apply this work to full economic evaluations to better understand and identify cost-effective infection mitigation strategies.
- ItemOpen AccessValidating administrative data to identify complex surgical site infections following cardiac implantable electronic device implantation: a comparison of traditional methods and machine learning(2022-11-10) Rennert-May, Elissa; Leal, Jenine; MacDonald, Matthew K.; Cannon, Kristine; Smith, Stephanie; Exner, Derek; Larios, Oscar E.; Bush, Kathryn; Chew, DerekAbstract Background Cardiac implantable electronic device (CIED) surgical site infections (SSIs) have been outpacing the increases in implantation of these devices. While traditional surveillance of these SSIs by infection prevention and control would likely be the most accurate, this is not practical in many centers where resources are constrained. Therefore, we explored the validity of administrative data at identifying these SSIs. Methods We used a cohort of all patients with CIED implantation in Calgary, Alberta where traditional surveillance was done for infections from Jan 1, 2013 to December 31, 2019. We used this infection subgroup as our “gold standard” and then utilized various combinations of administrative data to determine which best optimized the sensitivity and specificity at identifying infection. We evaluated six approaches to identifying CIED infection using administrative data, which included four algorithms using International Classification of Diseases codes and/or Canadian Classification of Health Intervention codes, and two machine learning models. A secondary objective of our study was to assess if machine learning techniques with training of logistic regression models would outperform our pre-selected codes. Results We determined that all of the pre-selected algorithms performed well at identifying CIED infections but the machine learning model was able to produce the optimal method of identification with an area under the receiver operating characteristic curve (AUC) of 96.8%. The best performing pre-selected algorithm yielded an AUC of 94.6%. Conclusions Our findings suggest that administrative data can be used to effectively identify CIED infections. While machine learning performed the most optimally, in centers with limited analytic capabilities a simpler algorithm of pre-selected codes also has excellent yield. This can be valuable for centers without traditional surveillance to follow trends in SSIs over time and identify when rates of infection are increasing. This can lead to enhanced interventions for prevention of SSIs.
- ItemEmbargoWastewater-Based Surveillance of Antimicrobial Resistance Genes in Hospitals(2024-01-04) Au, Emily; Parkins, Michael; Conly, John; Harrison, Joe; Pitout, Johann; Rennert-May, ElissaBackground: Antimicrobial resistance poses a significant threat to public health and healthcare-associated infections with antimicrobial-resistant organisms contribute to increased patient morbidity, mortality, and healthcare costs. We adapted wastewater-based surveillance (WBS) as a novel tool to quantify and longitudinally monitor the abundance of antimicrobial resistance genes (ARGs) comprehensively and inclusively in tertiary care hospitals. Methods: Wastewater was collected weekly from March 2022 to March 2023 from four Calgary hospitals: RGH (615 beds), PLC (517 beds), FMC (1100 beds), and ACH (141 beds). A Calgary wastewater treatment plant (WWTP) served as a community control (population ~1 million). DNA extracted from wastewater pellets was used to detect the following ARGs with qPCR: Clostridioides difficile (C. difficile 16S rRNA, tcdA, tcdB), vancomycin-resistant enterococci (vanA, vanB), and Gram-negative ARGs (blaNDM-like, blaVIM-like, mcr-like). ARG copy numbers were assessed as raw (copies/ mL of wastewater processed) and normalized with three fecal biomarkers (total bacterial 16S rRNA, Bacteroides HF183 16S rRNA, human 18S rRNA). Mann-Whitney comparisons were determined with GraphPad Prism (v9.0). Results: Across one year, all ARGS were detected in hospital and community wastewater with qPCR. Mean abundances of C. difficile 16S rRNA, tcdA, and tcdB normalized with bacterial 16S rRNA were respectively 1.5- to 62-, 1.4- to 6-, and 1- to 344-times greater in hospitals than the WWTP, but only significantly in RGH, PLC, and FMC (p<0.05). Mean 16S-normalized abundances of vanA and vanB were respectively 26- to 2953- and 1.7- 108-times higher in RGH, PLC, and FMC relative to the WWTP (p<0.0001). Mean 16S-normalized abundance of blaNDM-like was 8- to 184-times greater in all hospitals (p<0.01) and blaVIM-like was 2- to 95-times greater in PLC and FMC than the WWTP (p<0.0001). mcr-like resistance was only occasionally detected at low levels in hospitals and was considered non-significant. Conclusion: WBS is a novel tool that can be used in real time to monitor ARGs across a range of scales with the potential to augment antimicrobial stewardship and infection control programs and elucidate potential contributing factors of ARG selection and colonization.