The US Centers for Disease Control and Prevention (CDC), in 2019, designated Methicillin-resistant Staphylococcus aureus (MRSA) as a serious antimicrobial resistance threat. The risk of acquiring MRSA and suffering life-threatening consequences due to it remains especially high for hospitalized patients due to a unique combination of factors, including: co-morbid conditions, immuno suppression, antibiotic use, and risk of contact with contaminated hospital workers and equipment. In this paper, we present a novel generative probabilistic model, GenHAI, for modeling sequences of MRSA test results outcomes for patients during a single hospitalization. This model can be used to answer many important questions from the perspectives of hospital administrators for mitigating the risk of MRSA infections. Our model is based on the probabilistic programming paradigm, and can be used to approximately answer a variety of predictive, causal, and counterfactual questions. We demonstrate the efficacy of our model by comparing it against discriminative and generative machine learning models using two real-world datasets.

A common type of zero-inflated data has certain true values incorrectly replaced by zeros due to data recording conventions (rare outcomes assumed to be absent) or details of data recording equipment (e.g. artificial zeros in gene expression data). Existing methods for zero-inflated data either fit the observed data likelihood via parametric mixture models that explicitly represent excess zeros, or aim to replace excess zeros by imputed values. If the goal of the analysis relies on knowing true data realizations, a particular challenge with zero-inflated data is identifiability, since it is difficult to correctly determine which observed zeros are real and which are inflated. This paper views zero-inflated data as a general type of missing data problem, where the observability indicator for a potentially censored variable is itself unobserved whenever a zero is recorded. We show that, without additional assumptions, target parameters involving a zero-inflated variable are not identified. However, if a proxy of the missingness indicator is observed, a modification of the effect restoration approach of Kuroki and Pearl allows identification and estimation, given the proxy-indicator relationship is known. If this relationship is unknown, our approach yields a partial identification strategy for sensitivity analysis. Specifically, we show that only certain proxy-indicator relationships are compatible with the observed data distribution. We give an analytic bound for this relationship in cases with a categorical outcome, which is sharp in certain models. For more complex cases, sharp numerical bounds may be computed using methods in Duarte et al. [2023]. We illustrate our method via simulation studies and a data application on central line-associated bloodstream infections (CLABSIs).

Beta-lactam- and in particular carbapenem-resistant Enterobacteriaceae represent a major public health threat. Despite strong variation of resistance across geographical settings, there is limited understanding of the underlying drivers. To assess these drivers, we developed a transmission model of cephalosporin- and carbapenem-resistant Klebsiella pneumoniae. The model is parameterized using antibiotic consumption and demographic data from eleven European countries and fitted to the resistance rates for Klebsiella pneumoniae for these settings. The impact of potential drivers of resistance is then assessed in counterfactual analyses. Based on reported consumption data, the model could simultaneously fit the prevalence of extended-spectrum beta-lactamase-producing and carbapenem-resistant Klebsiella pneumoniae (ESBL and CRK) across eleven European countries over eleven years. The fit could explain the large between-country variability of resistance in terms of consumption patterns and fitted differences in hospital transmission rates. Based on this fit, a counterfactual analysis found that reducing nosocomial transmission and antibiotic consumption in the hospital had the strongest impact on ESBL and CRK prevalence. Antibiotic consumption in the community also affected ESBL prevalence but its relative impact was weaker than inpatient consumption. Finally, we used the model to estimate a moderate fitness cost of CRK and ESBL at the population level. This work highlights the disproportionate role of antibiotic consumption in the hospital and of nosocomial transmission for resistance in gram-negative bacteria at a European level. This indicates that infection control and antibiotic stewardship measures should play a major role in limiting resistance even at the national or regional level.

OBJECTIVE: Timely availability of intravenous infusion pumps is critical for high-quality care delivery. Pumps are shared among hospital units, often without central management of their distribution. This study seeks to characterize unit-to-unit pump sharing and its impact on shortages, and to evaluate a system-control tool that balances inventory across all care areas, enabling increased availability of pumps. MATERIALS AND METHODS: A retrospective study of 3832 pumps moving in a network of 5292 radiofrequency and infrared sensors from January to November 2017 at The Johns Hopkins Hospital in Baltimore, Maryland. We used network analysis to determine whether pump inventory in one unit was associated with inventory fluctuations in others. We used a quasi-experimental design and segmented regressions to evaluate the effect of the system-control tool on enabling safe inventory levels in all care areas. RESULTS: We found 93 care areas connected through 67,111 pump transactions and 4 discernible clusters of pump sharing. Up to 17% (95% confidence interval, 7%-27%) of a unit's pump inventory was explained by the inventory of other units within its cluster. The network analysis supported design and deployment of a hospital-wide inventory balancing system, which resulted in a 44% (95% confidence interval, 36%-53%) increase in the number of care areas above safe inventory levels. CONCLUSIONS: Network phenomena are essential inputs to hospital equipment fleet management. Consequently, benefits of improved inventory management in strategic unit(s) are capable of spreading safer inventory levels throughout the hospital.

Theoretical models of infection spread on networks predict that targeting vaccination at individuals with a very large number of contacts (superspreaders) can reduce infection incidence by a significant margin. These models generally assume that superspreaders will always agree to be vaccinated. Hence, they cannot capture unintended consequences such as policy resistance, where the behavioral response induced by a new vaccine policy tends to reduce the expected benefits of the policy. Here, we couple a model of influenza transmission on an empirically-based contact network with a psychologically structured model of influenza vaccinating behavior, where individual vaccinating decisions depend on social learning and past experiences of perceived infections, vaccine complications and vaccine failures. We find that policy resistance almost completely undermines the effectiveness of superspreader strategies: the most commonly explored approaches that target a randomly chosen neighbor of an individual, or that preferentially choose neighbors with many contacts, provide at best a 2% relative improvement over their non-targeted counterpart as compared to 12% when behavioral feedbacks are ignored. Increased vaccine coverage in super spreaders is offset by decreased coverage in non-superspreaders, and superspreaders also have a higher rate of perceived vaccine failures on account of being infected more often. Including incentives for vaccination provides modest improvements in outcomes. We conclude that the design of influenza vaccine strategies involving widespread incentive use and/or targeting of superspreaders should account for policy resistance, and mitigate it whenever possible.