Browsing by Author "Leal, Jenine"

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    Barriers 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, Myles
    Alberta 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.
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    Clinical Features and Outcomes of Serotype 19A Invasive Pneumococcal Disease in Calgary, Alberta
    (2014-01-01) Ricketson, Leah J; Vanderkooi, Otto G; Wood, Melissa L; Leal, Jenine; Kellner, James D
    BACKGROUND: Streptoccocus pneumoniae serotype 19A (ST19A) became an important cause of invasive pneumococcal disease (IPD) after the introduction of the conjugate vaccine.OBJECTIVE: To examine the severity and outcome of ST19A IPD compared with non-ST19A IPD.METHODS: The Calgary Area Streptococcus pneumoniae Epidemiology Research (CASPER) study collects clinical and laboratory data on all IPD cases in Calgary, Alberta. Analysis was performed on data from 2000 to 2010 comparing ST19A and non-ST19A IPD cases. Adjusted linear and logistic regression models were used to examine outcomes of duration of appropriate intravenous antibiotic therapy and intensive care unit admission, respectively.RESULTS: ST19A tended to cause disease in younger patients. ST19A isolates were more often multidrug resistant (19% versus 0.3%; Pud_less_than0.001). Adjusted logistic regression showed no difference in intensive care unit admission between ST19A and non-ST19A IPD cases (OR 1.4 [95% CI 0.8 to 2.7]). An adjusted linear regression model showed patients ud_less_than18 years of age with a diagnosis of bacteremia and no risk factors infected with ST19A were, on average, treated with antibiotics 1.4 times (95% CI 1.1 to 1.9) as long as patients with non-19A IPD and the same baseline characteristics.DISCUSSION: ST19A IPD was associated with an increase in average time on antibiotics. Although many of the infecting strains of ST19A were within the threshold for susceptibility, they may be sufficiently resilient to require a longer duration of antibiotic therapy or higher dose to clear the infection.CONCLUSIONS: ST19A is more common in younger individuals, is more antibiotic resistant and may require longer average treatment duration.
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    Development and evaluation of virtual simulation games to increase the confidence and self-efficacy of healthcare learners in vaccine communication, advocacy, and promotion
    (2024-02-25) Doucette, Emily J.; Fullerton, Madison M.; Pateman, Margaret; Lip, Alyssa; Houle, Sherilyn K.; Kellner, James D.; Leal, Jenine; MacDonald, Shannon E.; McNeil, Deborah; Tyerman, Jane; Luctkar-Flude, Marian; Davidson, Sandra; Constantinescu, Cora
    Abstract Background Although healthcare providers (HCPs) are the most trusted source of vaccine information, there is a paucity of easily accessible, multidisciplinary educational tools on vaccine communication for them. Virtual simulation games (VSGs) are innovative yet accessible and effective tools in healthcare education. The objectives of our study were to develop VSGs to increase HCP confidence and self-efficacy in vaccine communication, advocacy, and promotion, and evaluate the VSGs’ effectiveness using a pre-post self-assessment pilot study. Methods A multidisciplinary team of experts in medicine, nursing, pharmacy, and simulation development created three VSGs for HCP learners focused on addressing conversations with vaccine hesitant individuals. We evaluated the VSGs with 24 nursing students, 30 pharmacy students, and 18 medical residents who completed surveys and 6-point Likert scale pre-post self-assessments to measure changes in their confidence and self-efficacy. Results There were no significant differences in baseline confidence and self-efficacy across the three HCP disciplines, despite varied levels of education. Post-VSG confidence and self-efficacy (median: 5) were significantly higher than pre-VSG (median: 4–5) for all three HCP disciplines (P ≤ 0.0005), highlighting the effectiveness of the VSGs. Medical residents reported significantly lower post-VSG confidence and self-efficacy than nursing and pharmacy learners despite completing the most significant amount of education. Conclusions Following the completion of the VSGs, learners in medicine, nursing, and pharmacy showed significant improvement in their self-assessed confidence and self-efficacy in holding vaccine conversations. The VSGs as an educational tool, in combination with existing clinical immunization training, can be used to increase HCP confidence and engagement in vaccine discussions with patients, which may ultimately lead to increased vaccine confidence among patients.
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    Development of machine learning models for the detection of surgical site infections following total hip and knee arthroplasty: a multicenter cohort study
    (2023-09-02) Wu, Guosong; Cheligeer, Cheligeer; Southern, Danielle A.; Martin, Elliot A.; Xu, Yuan; Leal, Jenine; Ellison, Jennifer; Bush, Kathryn; Williamson, Tyler; Quan, Hude; Eastwood, Cathy A.
    Abstract Background Population based surveillance of surgical site infections (SSIs) requires precise case-finding strategies. We sought to develop and validate machine learning models to automate the process of complex (deep incisional/organ space) SSIs case detection. Methods This retrospective cohort study included adult patients (age ≥ 18 years) admitted to Calgary, Canada acute care hospitals who underwent primary total elective hip (THA) or knee (TKA) arthroplasty between Jan 1st, 2013 and Aug 31st, 2020. True SSI conditions were judged by the Alberta Health Services Infection Prevention and Control (IPC) program staff. Using the IPC cases as labels, we developed and validated nine XGBoost models to identify deep incisional SSIs, organ space SSIs and complex SSIs using administrative data, electronic medical records (EMR) free text data, and both. The performance of machine learning models was assessed by sensitivity, specificity, positive predictive value, negative predictive value, F1 score, the area under the receiver operating characteristic curve (ROC AUC) and the area under the precision–recall curve (PR AUC). In addition, a bootstrap 95% confidence interval (95% CI) was calculated. Results There were 22,059 unique patients with 27,360 hospital admissions resulting in 88,351 days of hospital stay. This included 16,561 (60.5%) TKA and 10,799 (39.5%) THA procedures. There were 235 ascertained SSIs. Of them, 77 (32.8%) were superficial incisional SSIs, 57 (24.3%) were deep incisional SSIs, and 101 (42.9%) were organ space SSIs. The incidence rates were 0.37 for superficial incisional SSIs, 0.21 for deep incisional SSIs, 0.37 for organ space and 0.58 for complex SSIs per 100 surgical procedures, respectively. The optimal XGBoost models using administrative data and text data combined achieved a ROC AUC of 0.906 (95% CI 0.835–0.978), PR AUC of 0.637 (95% CI 0.528–0.746), and F1 score of 0.79 (0.67–0.90). Conclusions Our findings suggest machine learning models derived from administrative data and EMR text data achieved high performance and can be used to automate the detection of complex SSIs.
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    Economic 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, Braden
    Abstract 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.
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    Healthcare 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, Jenine
    Abstract 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.
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    Implementation strategies for hospital-based probiotic administration in a stepped-wedge cluster randomized trial design for preventing hospital-acquired Clostridioides difficile infection
    (2023-12-11) Bresee, Lauren C.; Lamont, Nicole; Ocampo, Wrechelle; Holroyd-Leduc, Jayna; Sabuda, Deana; Leal, Jenine; Dalton, Bruce; Kaufman, Jaime; Missaghi, Bayan; Kim, Joseph; Larios, Oscar E.; Henderson, Elizabeth; Raman, Maitreyi; Fletcher, Jared R.; Faris, Peter; Kraft, Scott; Shen, Ye; Louie, Thomas; Conly, John M.
    Abstract Background Clostridioides difficile infection (CDI) is associated with considerable morbidity and mortality in hospitalized patients, especially among older adults. Probiotics have been evaluated to prevent hospital-acquired (HA) CDI in patients who are receiving systemic antibiotics, but the implementation of timely probiotic administration remains a challenge. We evaluated methods for effective probiotic implementation across a large health region as part of a study to assess the real-world effectiveness of a probiotic to prevent HA-CDI (Prevent CDI-55 +). Methods We used a stepped-wedge cluster-randomized controlled trial across four acute-care adult hospitals (n = 2,490 beds) to implement the use of the probiotic Bio-K + ® (Lactobacillus acidophilus CL1285®, L. casei LBC80R® and L. rhamnosus CLR2®; Laval, Quebec, Canada) in patients 55 years and older receiving systemic antimicrobials. The multifaceted probiotic implementation strategy included electronic clinical decision support, local site champions, and both health care provider and patient educational interventions. Focus groups were conducted during study implementation to identify ongoing barriers and facilitators to probiotic implementation, guiding needed adaptations of the implementation strategy. Focus groups were thematically analyzed using the Theoretical Domains Framework and the Consolidated Framework of Implementation Research. Results A total of 340 education sessions with over 1,800 key partners and participants occurred before and during implementation in each of the four hospitals. Site champions were identified for each included hospital, and both electronic clinical decision support and printed educational resources were available to health care providers and patients. A total of 15 individuals participated in 2 focus group and 7 interviews. Key barriers identified from the focus groups resulted in adaptation of the electronic clinical decision support and the addition of nursing education related to probiotic administration. As a result of modifying implementation strategies for identified behaviour change barriers, probiotic adherence rates were from 66.7 to 75.8% at 72 h of starting antibiotic therapy across the four participating acute care hospitals. Conclusions Use of a barrier-targeted multifaceted approach, including electronic clinical decision support, education, focus groups to guide the adaptation of the implementation plan, and local site champions, resulted in a high probiotic adherence rate in the Prevent CDI-55 + study.
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    Incidence, risk factors, and outcomes of Fusobacterium species bacteremia
    (BioMed Central, 2013-06-05) Afra, Kevin; Laupland, Kevin; Leal, Jenine; Lloyd, Tracie; Gregson, Daniel B.
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    Patient and ward related risk factors in a multi-ward nosocomial outbreak of COVID-19: Outbreak investigation and matched case–control study
    (2023-03-22) Leal, Jenine; O’Grady, Heidi M.; Armstrong, Logan; Dixit, Devika; Khawaja, Zoha; Snedeker, Kate; Ellison, Jennifer; Erebor, Joyce; Jamieson, Peter; Weiss, Amanda; Salcedo, Daniel; Roberts, Kimberley; Wiens, Karen; Croxen, Matthew A.; Berenger, Byron M.; Pabbaraju, Kanti; Lin, Yi-Chan; Evans, David; Conly, John M.
    Abstract Background Risk factors for nosocomial COVID-19 outbreaks continue to evolve. The aim of this study was to investigate a multi-ward nosocomial outbreak of COVID-19 between 1st September and 15th November 2020, occurring in a setting without vaccination for any healthcare workers or patients. Methods Outbreak report and retrospective, matched case–control study using incidence density sampling in three cardiac wards in an 1100-bed tertiary teaching hospital in Calgary, Alberta, Canada. Patients were confirmed/probable COVID-19 cases and contemporaneous control patients without COVID-19. COVID-19 outbreak definitions were based on Public Health guidelines. Clinical and environmental specimens were tested by RT-PCR and as applicable quantitative viral cultures and whole genome sequencing were conducted. Controls were inpatients on the cardiac wards during the study period confirmed to be without COVID-19, matched to outbreak cases by time of symptom onset dates, age within ± 15 years and were admitted in hospital for at least 2 days. Demographics, Braden Score, baseline medications, laboratory measures, co-morbidities, and hospitalization characteristics were collected on cases and controls. Univariate and multivariate conditional logistical regression was used to identify independent risk factors for nosocomial COVID-19. Results The outbreak involved 42 healthcare workers and 39 patients. The strongest independent risk factor for nosocomial COVID-19 (IRR 3.21, 95% CI 1.47–7.02) was exposure in a multi-bedded room. Of 45 strains successfully sequenced, 44 (97.8%) were B.1.128 and differed from the most common circulating community lineages. SARS-CoV-2 positive cultures were detected in 56.7% (34/60) of clinical and environmental specimens. The multidisciplinary outbreak team observed eleven contributing events to transmission during the outbreak. Conclusions Transmission routes of SARS-CoV-2 in hospital outbreaks are complex; however multi-bedded rooms play a significant role in the transmission of SARS-CoV-2.
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    Risk of transmission of respiratory viruses during aerosol-generating medical procedures (AGMPs) revisited in the COVID-19 pandemic: a systematic review
    (2022-08-11) Leal, Jenine; Farkas, Brenlea; Mastikhina, Liza; Flanagan, Jordyn; Skidmore, Becky; Salmon, Charleen; Dixit, Devika; Smith, Stephanie; Tsekrekos, Stephen; Lee, Bonita; Vayalumkal, Joseph; Dunn, Jessica; Harrison, Robyn; Cordoviz, Melody; Dubois, Roberta; Chandran, Uma; Clement, Fiona; Bush, Kathryn; Conly, John; Larios, Oscar
    Abstract Background In many jurisdictions healthcare workers (HCWs) are using respirators for aerosol-generating medical procedures (AGMPs) performed on adult and pediatric populations with all suspect/confirmed viral respiratory infections (VRIs). This systematic review assessed the risk of VRIs to HCWs in the presence of AGMPs, the role respirators versus medical/surgical masks have on reducing that risk, and if the risk to HCWs during AGMPs differed when caring for adult or pediatric patient populations. Main text We searched MEDLINE, EMBASE, Cochrane Central, Cochrane SR, CINAHL, COVID-19 specific resources, and MedRxiv for English and French articles from database inception to September 9, 2021. Independent reviewers screened abstracts using pre-defined criteria, reviewed full-text articles, selected relevant studies, abstracted data, and conducted quality assessments of all studies using the ROBINS-I risk of bias tool. Disagreements were resolved by consensus. Thirty-eight studies were included; 23 studies on COVID-19, 10 on SARS, and 5 on MERS/ influenza/other respiratory viruses. Two of the 16 studies which assessed associations found that HCWs were 1.7 to 2.5 times more likely to contract COVID-19 after exposure to AGMPs vs. not exposed to AGMPs. Eight studies reported statistically significant associations for nine specific AGMPs and transmission of SARS to HCWS. Intubation was consistently associated with an increased risk of SARS. HCWs were more likely (OR 2.05, 95% CI 1.2–3.4) to contract human coronaviruses when exposed to an AGMP in one study. There were no reported associations between AGMP exposure and transmission of influenza or in a single study on MERS. There was limited evidence supporting the use of a respirator over a medical/surgical mask during an AGMP to reduce the risk of viral transmission. One study described outcomes of HCWs exposed to a pediatric patient during intubation. Conclusion Exposure to an AGMP may increase the risk of transmission of COVID-19, SARS, and human coronaviruses to HCWs, however the evidence base is heterogenous and prone to confounding, particularly related to COVID-19. There continues to be a significant research gap in the epidemiology of the risk of VRIs among HCWs during AGMPs, particularly for pediatric patients. Further evidence is needed regarding what constitutes an AGMP.
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    The 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, Jenine
    Abstract 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.
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    Validating 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, Derek
    Abstract 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.