Evidence Synthesis

Investigator

Sherri Jobin

• Fairview Health Services

The Problem

Different Fairview Hospitals use different practices to administer beta-lactam antibiotics, specifically piperacillin-tazobactam. Some sites use an extended or prolonged infusion strategy, while others use a standard, intermittent infusion strategy. This variation is confusing for providers who move between hospitals.

The Intervention

Evidence Synthesis conducted this rapid review in response to a request from the Fairview Pharmacy Department, who wanted to standardize the practice and ensure all patients are receiving the same quality of care.

Prolonged infusions have both theoretical benefits and potential drawbacks, making it unclear which infusion strategy is the most effective. In this project, we reviewed the appropriate dosage and use of prolonged versus standard infusions of piperacillin-tazobactam.

Outcomes

We found four recent systematic reviews (Fawaz, 2020; Rhodes, 2018; Yang, 2016; Yang, 2015), and four high-quality randomized controlled trials (Chongcharoenyanon, 2021; Lyu, 2018; Naiim, 2022; Yang, 2017) that compared different infusion lengths and timing.

• Patients who received continuous, prolonged infusions were significantly more likely to be cured of their clinical conditions.
• The systematic reviews suggested that patients who received prolonged infusions had significantly less mortality, while only one randomized controlled trial found a difference.
• There were conflicting findings on if prolonged infusions affected patients’ length of stay and their odds of adverse effects or microbiological cure.
• Prolonged infusions are possibly more effective than standard infusions.

We did not find any studies that compared different dosages of piperacillin-tazobactam.

Investigator

Cindy Larson, PhD

• Fairview Health Services

The Problem

Total joint arthroplasty (TJA) is among the most common surgeries performed in the United States. The goal of arthroplasty is to improve function and quality of life, generally in older adults. Periprosthetic joint infection (PJI) occurs in up to 2% of arthroplasty recipients overall and is one of the most serious adverse events related to TJA, often with long-term consequences.

Wound irrigation (lavage) is a surgical wound washout process used during arthroplasty procedures to remove debris from the operative wound and reduce microbial contamination that can lead to infection. In primary arthroplasty, the main goals of surgical lavage are to prevent surgical site infection (SSI) and microbial biofilm development and aid visualization of the operative area.

The Intervention

Evidence Synthesis conducted this rapid review in response to a request from a clinical working group interested in understanding two different wound lavage solutions and their comparative effectiveness in TJA, and revision arthroplasty in particular.

The two lavage options of interest were Bactisure® and Irrisept®. The Bactisure® Wound Lavage (BWL) system includes a 1000 mL bag of aqueous solution to remove debris from surgical wounds using pulsed (jet) lavage followed by saline, and is often used for revision arthroplasty surgeries. BWL was specifically designed to deconstruct and remove biofilm to make bacteria more susceptible to antibiotics. Irrisept®, a 0.05% chlorhexidine gluconate in sterile water jet lavage irrigation solution, has bactericidal and anti-biofilm properties and is used for lavage in orthopedic surgery, in addition to general surgery and urology.

Outcomes

• We found a striking absence of randomized trials on the comparative effectiveness of surgical lavage solutions used during elective arthroplasty surgeries. Large cohort studies with a concurrent comparison group are also absent. 
• Based on clinical studies to date, there is insufficient clinical evidence to determine the efficacy or comparative effectiveness of Bactisure™ or Irrisept® wound lavage for the prevention or treatment of infections associated with total joint arthroplasty of the hip, knee or shoulder. 
• The biomedical literature suggests that there remain great uncertainties around which specific agent or combinations thereof best prevents prosthetic joint infections or removes biofilm.
• Nonetheless, if Bactisure™ does have biofilm-busting capabilities that translate from in vitro to clinical settings, then Bactisure™ would likely be indicated for revision arthroplasty when infection (PJI) is present and known, provided the risk of adverse effects (e.g. cytotoxicity) is small. 
• There are several limitations of this rapid review. Our searches focused on arthroplasty and specific irrigants, so we excluded evidence from other subspecialties, when identified.

Investigator

Bhargavi Ghate

• Fairview Health Services

The Problem

The Patient-Reported Outcomes Measurement Information System Global Health survey (PROMIS-GH) is a questionnaire used broadly across Fairview Health Services to measure the outcomes of adult and pediatric patients with depression.

The Intervention

Evidence Synthesis conducted this rapid review in response to a request from a clinical working group interested in interpreting and incorporating the depression-specific measures/scores in PROMIS-GH into clinical practice.

This investigation into PROMIS-GH is part of the group’s larger work of looking at Fairview’s continuum of care for patients with depression and creating a care maplet.

For this project, our team examined the minimally important changes (MICs) in PROMIS-GH scores in patients with chronic pain, anxiety, post-traumatic stress disorder, depression, or other mental health conditions.

Outcomes

• Current research literature supports reporting the 10-item PROMIS-GH score as two subscores: PROMIS Physical Health (PROMIS-PH) and PROMIS Mental Health (PROMIS-MH).
• While a number of studies calculated MIC values for other PROMIS scales, none calculated an MIC for the PROMIS-MH subscore.
• No studies focused on patients with depression or used PROMIS-GH exclusively for mental health and chronic pain patients.

Investigator

Terese Hill

• Fairview Health Services

The Problem

Food is Medicine (FIM) is an initiative through the Center for Community Health Equity that aims to reduce food insecurity and chronic diet related conditions among patients and improve health outcomes. The initiative also aims to reduce burden on providers and the total cost of care for the health system.

FIM programming has been implemented across Fairview Health Services for a number of years. The programming includes food distribution, monthly payments for groceries, classes to improve food skills, and more.

The Intervention

Evidence Synthesis conducted this review in response to a request from Fairview Health Services seeking an investigation into the impact of FIM programming as well as a review of other food insecurity interventions that could potentially be implemented.

Outcomes

A large number of studies on food interventions were identified. The three main types of interventions discussed were referrals to community organizations, food or food vouchers, and a combination of referrals, food, and/or nutrition education.

• Food/food vouchers significantly reduced food insecurity both alone and when combined with nutrition education.
• A web screening tool that referred patients to various agencies also reduced food insecurity (Hassan, 2015).
• While there were mixed results on clinical outcomes, many interventions involving food/food vouchers and food/food vouchers with nutrition education improved patients’ BMI and blood glucose.
• One intervention that involved screening and referring pregnant patients to a food resources program improved their blood pressure but did not have a significant effect on their blood glucose (Morales, 2016).
• The effects of interventions on healthcare utilization and costs were also mixed.
• Patients enrolled in a meal delivery program used emergency services significantly less (Berkowitz, 2018). Similarly, children given a combination of free formula, referrals, and nutrition education were more likely to seek preventative care (Beck, 2014).
• In other studies, patients receiving combinations of different interventions did not have significantly different healthcare utilization. One group that received referrals, food vouchers, and nutrition education even had lower numbers of patients attending follow-up appointments (Blistein, 2021). 

Research on food security interventions varies greatly in terms of the intervention applied, population studied, data collected, and outcomes measured. Because we did not assess the quality of the biomedical literature, we can’t assess the strength of the association between these interventions and their outcomes.

The Food is Medicine team will use the findings of Evidence Synthesis to design future programs and evaluations, in collaboration with CLHSS’s Practice Based Research Network.

Investigator

Sonja Short

• Fairview Health Services

The Problem

Evidence Synthesis conducted this rapid review in response to a request from a clinical working group interested in understanding antibiotic treatment recommendations for acute sinusitis.

The working group was most familiar with the clinical practice guidelines previously published by the Infectious Diseases Society of America (IDSA) and Institute for Clinical Systems Improvement (ICSI). However, both of these guidelines were outdated, and their recommendations conflicted with one another.

The Intervention

For this project, we assessed the quality of current (2018-present) clinical practice guidelines providing recommendations on antibiotic treatment for acute sinusitis.

Outcomes

We identified one high quality and current clinical practice guideline in our review - the European Position on Rhinosinusitis and Nasal Polyps 2020 (EPOS2020). The Appraisal of Guidelines for Research and Evaluation (AGREE II) tool was used to assess guideline quality.

A summary of the EPOS2020 guideline for treatment of acute sinusitis:

• The EPOS2020 guideline included recommendations based on three distinct types of acute rhinosinusitis (ARS): acute viral rhinosinusitis, acute post-viral rhinosinusitis, and acute bacterial rhinosinusitis.
• Antibiotics were recommended only for adults diagnosed with acute bacterial rhinosinusitis.
• From limited evidence, it appears beta-lactams are effective and fluoroquinolone is not.
• There was not enough data to make an antibiotic recommendation for children with acute bacterial rhinosinusitis.

We carried out further work to identify any randomized controlled trials using antibiotics to treat acute sinusitis published after the EPOS2020 publication (January 2019). Ten additional studies were identified and shared with the working group.