Trends in Collection of Microbiological Cultures Across Veterans Affairs Community Living Centers in the United States Over 8 Years

Abstract

Objectives: To describe and evaluate changes in the collection of microbiological cultures across Veterans Affairs (VA) Community Living Centers (CLCs) nationally. Design: Descriptive study. Setting: 146 VA CLCs. Participants: We identified both positive and negative microbiological cultures collected during VA CLC admissions from January 2010 through December 2017. Measures: We measured the average annual percentage change (AAPC) in the rate of cultures collected per 1000 bed days and per admission, overall and stratified by culture type (ie, urine, blood, skin and soft tissue, and respiratory tract). AAPCs were also calculated for the proportion and rate of positive cultures collected, overall and stratified by culture type and organism (ie, Escherichia coli, Proteus mirabilis, Staphylococcus aureus, Enterococcus spp, Pseudomonas aeruginosa, Klebsiella spp, Enterobacter spp, Morganella morganii, Citrobacter spp, Serratia marcescens, and Streptococcus pneumoniae). Joinpoint regression software was used to assess trends and estimate AAPCs and 95% confidence intervals (CIs). Results: Over 8 years, 355,329 cultures were collected. The rate of cultures collected per 1000 bed days of care decreased significantly by 6.0% per year (95% CI e8.7%, À3.2%). The proportion of positive cultures decreased by 0.9% (95% CI e1.4%, À0.4%). The most common culture types were urine (48.4%), followed by blood (27.7%). The rate of cultures collected per 1000 bed days of care decreased per year by 6.3% for urine, 5.0% for blood, 4.4% for skin and soft tissue, and 4.9% for respiratory tract. In 2010, S aureus was the most common organism identified, and in all subsequent years E coli was the most common. Conclusion and implications: We identified a significant reduction in the number of cultures collected over time among VA CLCs. Our findings may be explained by decreases in the collection of unnecessary

Progress and Challenges in the Management of Nursing Home Infections

“…Common challenges in this area include determining whether and when a pressure ulcer has deep tissue infection requiring antibiotics 11,12 ; avoiding the overdiagnosis of cellulitis for reddened skin areas (particularly in the lower extremities) 13,14 ; and minimizing overuse, inappropriate collection techniques, and overinterpretation of results of skin cultures. 15,16 This is indeed a challenging area, and one in which more nursing home research is needed.…”

“…However, overculturing or misinterpretation of culture results can lead to antibiotic misuse and contribute to the development of MDROs. 37 Therefore, appropriate use of microbial cultures is important in optimizing antibiotic use and often involves policy and practice changes such as removing policies that promote automatic culturing, introducing diagnostic algorithms, and creating alternative order sets promoting close monitoring over antibiotic prescribing when cultures are positive but patients are not ill. 38 This issue of JAMDA contains 2 articles that add to this knowledge baseda study documenting that hospital and nursing home cultures may differ markedly within the same geographic region 39 and a report indicating that microbial culture rates in US Veterans Affairs nursing homes have declined, likely in response to initiatives aimed at decreasing unnecessary cultures 15 dplus an editorial that provides guidance for nursing homes on best practices regarding antibiograms. 40…”

Are Antibiograms Ready for Prime Time in the Nursing Home?

“…The work by Appaneal and colleagues in this issue of JAMDA provides some hopeful evidence that our stewardship efforts are indeed working. 23 Analyzing national trends in the collection rate of microbiological cultures at Veterans Affairs (VA) long-term care facilities (known as Community Living Centers or CLC in the VA Healthcare System) over an 8-year period, they found a significant, steady annual decrease in the rate of cultures obtained. The number of cultures collected per admission declined by 8.3% per year and per 1000 resident-days by 6.0% annually.…”