NOSOCOMIAL INFECTION  

January 2006

Some Selected Abstracts:

1. 

Dettenkofer M, Block C.Hospital disinfection: efficacy and safety issues.
Curr Opin Infect Dis. 2005 Aug;18(4):320-5.

Institute of Environmental Medicine and Hospital Epidemiology, Freiburg University Hospital, Freiburg, Germany. markus.dettenkofer@uniklinik-freiburg.de

PURPOSE OF REVIEW: To review recent publications relevant to hospital disinfection (and cleaning) including the reprocessing of medical instruments. RECENT FINDINGS: The key question as to whether the use of disinfectants on environmental surfaces rather than cleaning with detergents only reduces nosocomial infection rates still awaits conclusive studies. New disinfectants, mainly peroxygen compounds, show good sporicidal properties and will probably replace more problematical substances such as chlorine-releasing agents. The safe reprocessing of medical devices requires a well-coordinated approach, starting with proper cleaning. New methods and substances show promising activity for preventing the transmission of prions. Different aspects of virus inactivation have been studied, and the transmissibility, e.g. of norovirus, shows the need for sound data on how different disinfectant classes perform. Biofilms or other forms of surface-adherent organisms pose an extraordinary challenge to decontamination. Although resistance to biocides is generally not judged to be as critical as antibiotic resistance, scientific data support the need for proper use, i.e. the avoidance of widespread application, especially in low concentrations and in consumer products. SUMMARY: Chemical disinfection of heat-sensitive instruments and targeted disinfection of environmental surfaces are established components of hospital infection control. To avoid danger to staff, patients and the environment, prudent use as well as established safety precautions are required. New technologies and products should be evaluated with sound methods. As emerging resistant pathogens will challenge healthcare facilities in the future even more than at present, there is a need for well-designed studies addressing the role of disinfection in hospital infection control.

2. 

Preston RM. Aseptic technique: evidence-based approach for patient safety. Br J Nurs. 2005 May 26-Jun 8;14(10):540-2, 544-6.

University of Luton.

The fact that there is a relationship between the standards of aseptic technique performance and the rise in hospital infection rates has been suggested by the Department of Heath's (DoH's, 2004) 'Winning Ways' document. This literature review considers how the aseptic technique is performed in the UK, and examines the nature of ritualistic and evidence-based practice underpinning this skill-based procedure. The findings have identified an emerging glove culture and continuing poor hand-hygiene practices. The alternative 'clean technique' is also adopted widely in clinical practice which confuses the aseptic theory-practice gap. While it is hard to pinpoint an actual time or event that causes infection, it is unlikely nurses will ever become involved in litigation as a result of a poorly performed aseptic technique. However, the review concludes that nurses should not become too complacent. It briefly considers how performance of the aseptic technique can be improved, through creative educational strategy, applied risk assessment and clinical audits of nurses' practices.

3.

Landrigan CP.The safety of inpatient pediatrics: preventing medical errors and injuries among hospitalized children. Pediatr Clin North Am. 2005 Aug;52(4):979-93, vii.

Inpatient Pediatrics Service, Children's Hospital Boston, 300 Longwood Avenue, Boston, MA 02115, USA. christopher.landrigan@childrens.harvard.edu

This article explores the current state of knowledge about the safety of hospitalized patients in general and patients in pediatric settings in particular. It discusses approaches to evaluating patient safety and reviews the current literature on adverse events and errors in hospitals. The article also discusses strategies proven effective in reducing medical errors and some of the barriers to implementing these strategies that must be overcome.

4.

Panhotra BR, Saxena AK, Al-Mulhim AS.Contamination of patients' files in intensive care units: an indication of strict handwashing after entering case notes. Am J Infect Control. 2005 Sep;33(7):398-401.

Department of Infection Control, King Fahad Hospital, Al-Hofuf, Saudi Arabia. drpanhotra2000@hotmail.com

BACKGROUND: The extent to which bedside patients' files become contaminated and the range of bacterial flora attributable to contamination in high-risk areas of the hospital are not known with certainty. The aim of the present study was to determine the degree of contamination of the patient's files and also to analyze and compare the spectrum of contaminant bacterial flora between the intensive care unit (ICU) and surgical wards, the 2 most high-risk areas for nosocomial transmission of infection. METHODS: Microbiologic samples were collected from the exposed outer surface of the patients' files kept bedside in the ICU and surgical wards with sterile swabs moistened with sterile normal saline. Swabs were cultured within an hour of collection on blood agar and MacConkey's agar plates, which were incubated at 37 degrees C for 48 hours. Gram-negative bacilli were identified by Gram's stain, catalase, oxidase tests, and API 20E and API 20NE. Staphylococcus species were identified by Gram's stain, catalase test, and tube coagulase test. Antibiotic susceptibility of the isolated bacteria was determined by the disk diffusion technique according to the criteria of National Committee for Clinical Laboratory Standards (NCCLS). RESULTS: In ICU, 85.2% (87/102) and, in surgical wards, 24.7% (22/89) of patient's files were found to be contaminated with pathogenic and potentially pathogenic bacteria (OR, 17.664; 95% CI: 8.050-39.423; P < .0001). Pseudomonas aeruginosa was the most commonly isolated bacteria (32.3%, 33/102) in ICUs, whereas Staphylococcus aureus was the peak contaminant (11.2%, 10/89) of the files in surgical wards. Methicillin-resistant Staphylococcus aureus (MRSA) was isolated from 6.8% (7/102) of ICU patient's files, whereas only 1.1% (1/89) of patient's files in surgical wards were contaminated with MRSA (OR, 6.484; 95% CI: 3.215-13.463; P < .0001).The multidrug-resistant P aeruginosa, Acinetobacter baumannii, Klebsiella pneumoniae, and Serretia marcesens isolated from the patient's files had the same antibiotic resistance pattern as of these bacteria isolated from the patients. CONCLUSION: The majority of the patient's files in ICUs were contaminated often with multidrug-resistant bacteria and even MRSA. Contaminated files could be a source of transmission of infection. To prevent this, handwashing practice should be strictly followed after attending the patient and before entering the case notes in the patient's file. The maintenance of good hand hygiene by the health care workers (HCWs) after handling contaminated files should perhaps be the most prudent approach to prevent patient-patient transmission of infection in high-risk areas including ICU and surgical wards.

5.

Philips BJ, Redman J, Brennan A, Wood D, Holliman R, Baines D, Baker EH. Glucose in bronchialaspirates increases the risk of respiratory MRSA in intubated patients. Thorax. 2005 Sep;60(9):761-4.

Glucose and Pulmonary Infection Group, Jenner Wing, St George's Hospital Medical School, London SW17 0RE, UK.

BACKGROUND: The risk of nosocomial infection is increased in critically ill patients by stress hyperglycaemia. Glucose is not normally detectable in airway secretions but appears as blood glucose levels exceed 6.7-9.7 mmol/l. We hypothesise that the presence of glucose in airway secretions in these patients predisposes to respiratory infection. METHODS: An association between glucose in bronchial aspirates and nosocomial respiratory infection was examined in 98 critically ill patients. Patients were included if they were expected to require ventilation for more than 48 hours. Bronchial aspirates were analysed for glucose and sent twice weekly for microbiological analysis and whenever an infection was suspected. RESULTS: Glucose was detected in bronchial aspirates of 58 of the 98 patients. These patients were more likely to have pathogenic bacteria than patients without glucose detected in bronchial aspirates (relative risk 2.4 (95% CI 1.5 to 3.8)). Patients with glucose were much more likely to have methicillin resistant Staphylococcus aureus (MRSA) than those without glucose in bronchial aspirates (relative risk 2.1 (95% CI 1.2 to 3.8)). Patients who became colonised or infected with MRSA had more infiltrates on their chest radiograph (p<0.001), an increased C reactive protein level (p<0.05), and a longer stay in the intensive care unit (p<0.01). Length of stay did not determine which patients acquired MRSA. CONCLUSION: The results imply a relationship between the presence of glucose in the airway and a risk of colonisation or infection with pathogenic bacteria including MRSA.

6.

Robson W, Newell J. Assessing, treating and managing patients with sepsis. Nurs Stand. 2005 Aug 24-30;19(50):56-64.

Accident and Emergency Department, Chesterfield Royal Hospital NHS Foundation Trust, Derbyshire. wayne.robson@chesterfieldroyal.nhs.uk

This article outlines the causes, signs and symptoms of systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis and septic shock, the implications and available treatments. The article also highlights a campaign to reduce the incidence of sepsis and reflects on efforts to reduce healthcare-associated infections.

Diagnosis, Diagnostics, Immunodiagnosis & Immunodiagnostics:  

13399.   Bouza E, Munoz P, Alonso R. Clinical manifestations, treatment and control of infections caused by Clostridium difficile. Clin Microbiol Infect. 2005 Jul;11 Suppl 4:57-64. Review.

13400.  Dendukuri N, Costa V, McGregor M, Brophy JM. Probiotic therapy for the prevention and treatment of Clostridium difficile-associated diarrhea: a systematic review. CMAJ. 2005 Jul 19;173(2):167-70. Review.

13401.  Gentry H, Cope S. Using silver to reduce catheter-associated urinary tract infections. Nurs Stand. 2005 Aug 24-30;19(50):51-4.

13402.  Kostadima E, Kaditis AG, Alexopoulos EI, Zakynthinos E, Sfyras D. Early gastrostomy reduces the rate of ventilator-associated pneumonia in stroke or head injury patients. Eur Respir J. 2005 Jul;26(1):106-11.

13403.  Leifer D. MRSA hotspots. Nurs Stand. 2005 Sep 7-13;19(52):20-1. 

13404.  Liu H, Mulholland SG. Appropriate antibiotic treatment of genitourinary infections in hospitalized patients. Am J Med. 2005 Jul;118(Suppl 7A):14S-20S. Review.

13405.  Philips BJ, Redman J, Brennan A, Wood D, Holliman R, Baines D, Baker EH. Glucose in bronchial aspirates increases the risk of respiratory MRSA in intubated patients. Thorax. 2005 Sep;60(9):761-4.

13406.   Robson W, Newell J. Assessing, treating and managing patients with sepsis. Nurs Stand. 2005 Aug 24-30;19(50):56-64. Review.

13407.   Simpson C, Clark AP. Nosocomial UTI: are we treating the catheter or the patient? Clin Nurse Spec. 2005 Jul-Aug;19(4):175-9. Review.

13408.   Wei SH, Chiu HH, Hung KC, Wang JH, Su BH, Lin HC, Lin TW, Lin HC. Epidemiologic trends in nosocomial bacteremia in a neonatal intensive care unit. J Microbiol Immunol Infect. 2005 Aug;38(4):283-8.
Pathogenesis:

13409.  Borer A, Gilad J, Smolyakov R, Eskira S, Peled N, Porat N, Hyam E, Trefler R, Riesenberg K, Schlaeffer F. Cell phones and Acinetobacter transmission. Emerg Infect Dis. 2005 Jul;11(7):116120-1.

13410.  Butler SO, Btaiche IF, Alaniz C. Relationship between hyperglycemia and infection in critically ill patients. Pharmacotherapy. 2005 Jul;25(7):963-76. Review. 

13411.  Collins F, Hampton S. Hand-washing and methicillin-resistant Staphylococcus aureus. Br J Nurs. 2005 Jul 14-27;14(13):703-7. Review.

13412.  Ingram P, Lavery I. Peripheral intravenous therapy: key risks and implications for practice. Nurs Stand. 2005 Jul 27-Aug 2;19(46):55-64; quiz 66. Review.

13413.  Jain SK, Persaud D, Perl TM, Pass MA, Murphy KM, Pisciotta JM, Scholl PF, Casella JF, Sullivan DJ. Nosocomial malaria and saline flush. Emerg Infect Dis. 2005 Jul;11(7):1097-9.

13414.  Lim SM, Webb SA. Nosocomial bacterial infections in Intensive Care Units. I: Organisms and mechanisms of antibiotic resistance. Anaesthesia. 2005 Sep;60(9):887-902. Review.

13415.  Lipsett PA. Can we take the teeth out of ventilator-associated pneumonia? Crit Care Med. 2005 Aug;33(8):1867-8.

13416.  Lopez Dupla M, Martinez JA, Vidal F, Almela M, Lopez J, Marco F, Soriano A, Richart C, Mensa J. Clinical characterization of breakthrough bacteraemia: a survey of 392 episodes. J Intern Med. 2005 Aug;258(2):172-80.

13417.  MacDougall C, Harpe SE, Powell JP, Johnson CK, Edmond MB, Polk RE. Pseudomonas aeruginosa, Staphylococcus aureus, and fluoroquinolone use. Emerg Infect Dis. 2005 Aug;11(8):1197-204. 

13418.  Macias AE, Munoz JM, Galvan A, Gonzalez JA, Medina H, Alpuche C, Cortes G, Ponce-de-Leon S. Nosocomial bacteremia in neonates related to poor standards of care. Pediatr Infect Dis J. 2005 Aug;24(8):713-6. 

13419. Panhotra BR, Saxena AK, Al-Mulhim AS. Contamination of patients' files in intensive care units: an indication of strict handwashing after entering case notes. Am J Infect Control. 2005 Sep;33(7):398-401.

Therapy:

13420.  Bertini G, Perugi S, Dani C, Filippi L, Pratesi S, Rubaltelli FF. Fluconazole prophylaxis prevents invasive fungal infection in high-risk, very low birth weight infants. J Pediatr. 2005 Aug;147(2):162-5.

13421.  Blot S.  MRSA pneumonia: better outcome through continuous infusion of vancomycin? Crit Care Med. 2005 Sep;33(9):2127-8.

13422.  Bristol N. Patient safety alliance to tackle hand washing worldwide. Lancet. 2005 Sep 17-23;366(9490):973-4.

13423.  Castelli GP, Pognani C, Stuani A, Cita M, Paladini R, Gattuso G. Risk factors for CVC-related infections in ICUs: evaluation of time, type and number of cannulations. J Hosp Infect. 2005 Jul;60(3):286-7.

13424.  Dettenkofer M, Block C. Hospital disinfection: efficacy and safety issues. Curr Opin Infect Dis. 2005 Aug;18(4):320-5. Review.

13425.  Kmietowicz Z. Doctors to consider scrubs to reduce infection. BMJ. 2005 Jul 2;331(7507):9.

13426.  Landrigan CP. The safety of inpatient pediatrics: preventing medical errors and injuries among hospitalized children. Pediatr Clin North Am. 2005 Aug;52(4):979-93, vii. Review.

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April 2006

Some Selected Abstracts:

1. 

Moodley P, Coovadia YM, Sturm AW. Intravenous glucose preparation as the source of an outbreak of extended-spectrum beta-lactamase-producing Klebsiella pneumoniae infections in the neonatal unit of a regional hospital in KwaZulu-Natal. S Afr Med J. 2005 Nov;95(11):861-4.

Department of Medical Microbiology, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa.

In the last week of May 2005, staff at Mahatma Gandhi Memorial Hospital in KwaZulu-Natal realised that many babies in the high-care nursery ward had bloodstream infections involving Klebsiella pneumoniae bacteria. Attempts to identify a common source of infection failed. The ward was therefore closed and new babies needing high care were admitted to another empty ward. Despite this, babies still became infected. This resulted in a request for assistance from the Department of Medical Microbiology of the Nelson R Mandela School of Medicine. A search for common factors through case history studies of the 26 infected babies showed that blood cultures of the babies remained positive despite the administration of appropriate antibiotics. Different options that could explain this were investigated. The organism was found in intravenous glucose preparations used for multiple dosing. Unopened vials of the same medication were sterile. The nursery was found to lack proper hand-wash facilities and to be overcrowded and understaffed. Reinforcement of hand hygiene and a ban on the multiple dosing of medicines stopped the outbreak. In conclusion, this outbreak resulted from a combination of factors among which lack of hand hygiene and multiple dosing of an intravenous glucose preparation were most significant.

Diagnosis, Diagnostics, Immunodiagnosis & Immunodiagnostics:  

13960 .  Earsing KA, Hobson DB, White KM. Best-practice protocols: preventing central line infection. Nurs Manage. 2005 Oct;36(10):18-24.

13961.  Jensen PA, Lambert LA, Iademarco MF, Ridzon R; CDC. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. MMWR Recomm Rep. 2005 Dec 30;54(17):1-141.

13962.   Pruitt B. Keeping respiratory syncytial virus at bay. Nursing. 2005 Nov;35(11):62-4. Review. 

13963.   Salgado CD, O'Grady N, Farr BM. Prevention and control of antimicrobial-resistant infections in intensive care patients. Crit Care Med. 2005 Oct;33(10):2373-82. Review.

13964.    Shorr AF, Kollef MH. Ventilator-associated pneumonia: insights from recent clinical trials. Chest. 2005 Nov;128(5 Suppl 2):583S-591S.

13965.   Soylu A, Kavukcu S, Erdur B, Demir K, Turkmen MA. Multisystemic leukocytoclastic vasculitis affecting the central nervous system. Pediatr Neurol. 2005 Oct;33(4):289-91. 

 
Pathogenesis:

13966.     Baughman RP, Glauser MP. Managing serious infections in the hospital: a new model. Clin Microbiol Infect. 2005 Oct;11 Suppl 5:1-3.  

13967.   Bustamante CI. Treatment of Candida infection: a view from the trenches! Curr Opin Infect Dis. 2005 Dec;18(6):490-5. Review.

13968.   El Helali N, Carbonne A, Naas T, Kerneis S, Fresco O, Giovangrandi Y, Fortineau N, Nordmann P, Astagneau P. Nosocomial outbreak of staphylococcal scalded skin syndrome in neonates: epidemiological investigation and control. J Hosp Infect. 2005 Oct;61(2):130-8.

13969.   Lode H. Management of serious nosocomial bacterial infections: do current therapeutic options meet the need? Clin Microbiol Infect. 2005 Oct;11(10):778-87. Review.

13970.   Rello J, Diaz E, Rodriguez A.  Advances in the management of pneumonia in the intensive care unit: review of current thinking.Clin Microbiol Infect. 2005 Oct;11 Suppl 5:30-8. Review.

13971.   Sun HK, Kuti JL, Nicolau DP. Pharmacodynamics of antimicrobials for the empirical treatment of nosocomial pneumonia: a report from the OPTAMA Program. Crit Care Med. 2005 Oct;33(10):2222-7.

13972.   Suresh GK. Improper stool disposal in neonatal units in developing countries: an unrecognized hazard for nosocomial infection. Pediatrics. 2005 Nov;116(5):1265.  

13973.   Weinstein RA, Bonten MJ. Controlling antibiotic-resistant bacteria: what's an intensivist to do? Crit Care Med. 2005 Oct;33(10):2446-7.  

 

Therapy:

13974.     Chudleigh J, Fletcher M, Gould D. Infection control in neonatal intensive care units. J Hosp Infect. 2005 Oct;61(2):123-9.

13975.  O'Neill JK, Rust P, Knight D, Ricketts DM. Greens could be bad for you: a study of the inappropriate use of theater greens. South Med J. 2005 Oct;98(10):1053-4.  

13976.   Pittet D, Donaldson L. Clean Care is Safer Care: a worldwide priority. Lancet. 2005 Oct 8;366(9493):1246-7.  

13977.   Robeznieks A. ICU effort saved lives, money: organizers. More than 70 hospitals took part in the Keystone: ICU program. Mod Healthc. 2005 Oct 17;35(42):16.   

13978.  Soulsby EJ. Resistance to antimicrobials in humans and animals. BMJ. 2005 Nov 26;331(7527):1219-20.    

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July 2006

 

Therapy:

14453. Prats G, Rossi V, Salvatori E, Mirelis B. Prulifloxacin: a new antibacterial fluoroquinolone. Expert Rev Anti Infect Ther. 2006 Feb;4(1):27-41. Review.

14454. Rice LB. Unmet medical needs in antibacterial therapy. Biochem Pharmacol. 2006 Mar 30;71(7):991-5.

14455. Whitby RM, McLaws ML. Comment on: Johnson PDR, et al. Efficacy of an alcohol/chlorhexidine hand hygiene program in a hospital with high rates of nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infection. Med J Aust 2005; 183: 509-19. Med J Aust. 2006 Mar 6;184(5):253-4.

 

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October 2006

 

Some selected abstract:

1

Cavalcante SS, Mota E, Silva LR, Teixeira LF, Cavalcante LB. Risk factors for developing nosocomial infections among pediatric patients. Pediatr Infect Dis J. 2006 May;25(5):438-45.

Department of Pediatrics, Federal University of Bahia, Brazil. suzy_sc@terra.com.br

BACKGROUND: Nosocomial infections (NIs) are important causes of morbidity and mortality in pediatric hospitals. Multiple factors contribute towards exposing children to the risk of infection when hospitalized, and some of them differ from those in adults. METHODS: This was a prospective study in a tertiary-level teaching pediatric hospital in Salvador, Bahia, Brazil, conducted from January to July, 2003, to describe the epidemiologic characteristics of NIs. Centers for Disease Control's standard definitions were used and the data recorded included intrinsic and extrinsic risk factors. RESULTS: We evaluated 808 patients. There were 143 episodes of NI in 124 patients (15.4%). The overall incidence of NI cases was 9.2 per 1,000 patient-days, with higher rates among children aged less than 1 year (P < 0.001) and those with nonsurgical clinical diseases (P < 0.001). Gastrointestinal infections (39.2%) and eye, ear, nose, throat or mouth infections (29.4%) were most common. The factors most closely associated with higher incidence of NI were respiratory disease on admission (incidence density ratio [IDR], 4.0; 95% confidence interval [CI], 2.83-5.72), another disease associated with admission diagnosis (IDR, 3.5; 95% CI, 2.41-5.02), nonsurgical clinical disease (IDR, 5.9; 95% CI, 3.92-8.85) and pediatric intensive care unit residence (IDR, 3.5; 95% CI, 1.91-6.28). The lengths of hospital stay for patients with and without nosocomial infection were, respectively, 14.1 days (SD, 20.5 days) and 5.1 days (SD, 6.6 days) (t = 121.76; P < 0.001). CONCLUSIONS: Nosocomial infections are a frequent complication in pediatrics. They are not necessarily related to invasive procedures but certainly are related to a group of factors that have particular characteristics in the pediatric age group.
 
2

Church D, Elsayed S, Reid O, Winston B, Lindsay R.Burn wound infections.  Clin Microbiol Rev. 2006 Apr;19(2):403-34.

Calgary Laboratory Services, 9-3535 Research Rd. N.W., Calgary, Alberta, Canada T2L 2K8. Deirdre.church@cls.ab.ca

Burns are one of the most common and devastating forms of trauma. Patients with serious thermal injury require immediate specialized care in order to minimize morbidity and mortality. Significant thermal injuries induce a state of immunosuppression that predisposes burn patients to infectious complications. A current summary of the classifications of burn wound infections, including their diagnosis, treatment, and prevention, is given. Early excision of the eschar has substantially decreased the incidence of invasive burn wound infection and secondary sepsis, but most deaths in severely burn-injured patients are still due to burn wound sepsis or complications due to inhalation injury. Burn patients are also at risk for developing sepsis secondary to pneumonia, catheter-related infections, and suppurative thrombophlebitis. The introduction of silver-impregnated devices (e.g., central lines and Foley urinary catheters) may reduce the incidence of nosocomial infections due to prolonged placement of these devices. Improved outcomes for severely burned patients have been attributed to medical advances in fluid resuscitation, nutritional support, pulmonary and burn wound care, and infection control practices.
 
3

Depuydt P, Myny D, Blot S. Nosocomial pneumonia: aetiology, diagnosis and treatment. Curr Opin Pulm Med. 2006 May;12(3):192-7.

Department of Intensive Care, Ghent University, De Pintelaan, Belgium. pieter.depuydt@ugent.be

PURPOSE OF REVIEW: This review highlights recent advances in the aetiology of nosocomial pneumonia, and in strategies to increase accuracy of diagnosis and antibiotic prescription while limiting unnecessary antibiotic consumption. RECENT FINDINGS: Bacterial pathogens still cause the bulk of nosocomial pneumonia and are of concern because of ever-rising antimicrobial resistance. Yet, the pathogenic role of fungal and viral organisms is increasingly recognized. Since early appropriate antimicrobial therapy is the cornerstone of an effective treatment, further studies have been conducted to improve appropriateness of early antibiotic therapy. De-escalation strategies combine initial broad-spectrum antibiotics to maximize early antibiotic coverage with a subsequent focusing of the antibiotic spectrum when the cause is identified. Invasive techniques probably do not alter the immediate outcome but have the potential to reduce unnecessary antibiotic exposure. Decisions to stop or change antibiotic therapy are hampered due to a lack of reliable parameters to assess the resolution of pneumonia. SUMMARY: Increasing antimicrobial resistance in nosocomial pneumonia both challenges treatment and mandates limitation of selection pressure by reducing antibiotic burden. Treating physicians should be both aggressive in initiating antimicrobials when suspecting nosocomial pneumonia but willing to discontinue antimicrobials when diagnostic results point to an alternative diagnosis. Efforts should be made to limit duration of antibiotic therapy when possible.
 
4

Miller PR, Partrick MS, Hoth JJ, Meredith JW, Chang MC.  A practical application of practice-based learning: development of an algorithm for empiric antibiotic coverage in ventilator-associated pneumonia. J Trauma. 2006 Apr;60(4):725-9; discussion 729-31.

Department of Surgery, Wake Forest University Bowman Gray School of Medicine, Winston-Salem, NC 27157, USA. pmiller@wfubmc.edu

BACKGROUND: Development of practice-based learning (PBL) is one of the core competencies required for resident education by the Accreditation Council for Graduate Medical Education, and specialty organizations including the American College of Surgeons have formed task forces to understand and disseminate information on this important concept. However, translating this concept into daily practice may be difficult. Our goal was to describe the successful application of PBL to patient care improvement with development of an algorithm for the empiric therapy of ventilator-associated pneumonia (VAP). METHODS: The algorithm development occurred in two phases. In phase 1, the microbiology and timing of VAP as diagnosed by bronchoalveolar lavage was reviewed over a 2-year period to allow for recognition of patterns of infection. In phase 2, based on these data, an algorithm for empiric antibiotic coverage that would ensure that the large majority of patients with VAP received adequate initial empiric therapy was developed and put into practice. The period of algorithm use was then examined to determine rate of adequate coverage and outcome. RESULTS:: In Phase 1, from January 1, 2000 to December 31 2001, 110 patients were diagnosed with VAP. Analysis of microbiology revealed a sharp increase in the recovery of nosocomial pathogens on postinjury day 7 (19% < day 7 versus 47% > or = day 7, p = 0.003). Adequate initial antibiotic coverage was seen in 74%. In Phase 2, an algorithm employing ampicillin- sulbactam for coverage of community- acquired pathogens before day 7 and cefipime for nosocomial coverage > or =day 7 was then employed from January 1, 2024 to December 31, 2003. Evaluation of 186 VAP cases during this interval revealed a similar distribution of nosocomial cases (13% < day 7 versus 64% > or = day 7, p < 0.0001). Empiric antibiotic therapy was adequate in 82% of cases <day 7 and 85% of cases > or =day 7: overall accuracy improved to 83% (p = 0.05). Mortality from phase 1 to phase 2 trended toward a decrease (21% versus 13%, p = 0.1). CONCLUSIONS: Application of the concept of PBL allowed for identification of local patterns of infection and development of an institution specific treatment algorithm that resulted in >80% adequate initial empiric coverage for VAP with a trend toward decreased mortality. PBL allows for alteration in practice based on local patterns and outcomes and has the potential to improve patient care.
 
5

Ramphal R, Ambrose PG. Extended-spectrum beta-lactamases and clinical outcomes: current data. Clin Infect Dis. 2006 Apr 15;42 Suppl 4:S164-72.

Department of Medicine, University of Florida Health Sciences Center, Gainesville, FL 32610, USA. ramphr@medmac.ufl.edu

Nosocomial infections caused by extended-spectrum beta-lactamase (ESBL)-producing gram-negative bacteria complicate therapy and limit treatment options. However, the clinical significance of infections caused by ESBL-producing bacteria remains unclear. A critical examination of the literature provides divergent views of the effect of ESBL carriage on morbidity and mortality and suggests that ESBL production may have its most marked effect on ceftazidime. Effective strategies for the empirical and directed treatment of infections caused by ESBL-producing pathogens include the use of carbapenems and, possibly, the fourth-generation cephalosporin cefepime. Studies indicate that the use of cefepime to treat serious nosocomial infections (e.g., bacteremia, pneumonia, and urinary tract infections) is associated with high rates of microbiological and clinical success. The probability of attaining time above the minimum inhibitory concentration targets of at least 70% of the dosing interval, an important pharmacodynamic indicator of clinical success, is higher with cefepime than with other antimicrobials against Escherichia coli and Klebsiella pneumoniae strains exhibiting ESBL phenotypes. However, for non-ESBL-producing strains, there is no difference in the time above the minimum inhibitory concentration between ceftazidime and cefepime. When used appropriately in institutional settings, cefepime reduces the overall use of cephalosporins, thereby decreasing selection pressure for presumptive ESBL-producing pathogens.

 
6

Wong GK, Chan MT, Boet R, Poon WS, Gin T. Intravenous magnesium sulfate after aneurysmal subarachnoid hemorrhage: a prospective randomized pilot study. J Neurosurg Anesthesiol. 2006 Apr;18(2):142-8.

Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region.

We performed a randomized, double-blind, pilot study on magnesium sulfate (MgSO4) infusion for aneurysmal subarachnoid hemorrhage (SAH).Sixty patients with SAH were randomly allocated to receive either MgSO4 80 mmol/day or saline infusion for 14 days. Patients also received intravenous nimodipine. Episodes of vasospasm were treated with hypertensive and hypervolemic therapy. Neurologic status was assessed 6 months after hemorrhage using the Barthel index and Glasgow Outcome Scale. Incidences of cardiac and pulmonary complications were also recorded.Patient characteristics, severity of SAH, and surgical treatment did not differ between groups. The incidence of symptomatic vasospasm decreased from 43% in the saline group to 23% in patients receiving MgSO4 infusion, but it did not reach statistical significance, P=0.06. For patients who had transcranial Doppler-detected vasospasm, defined as mean flow velocity >120 cm/s and a Lindegaard index >3, the duration was shorter in the magnesium group compared with controls (P<0.01). There was, however, no difference between groups in functional recovery or Glasgow Outcome Scale score. The incidence of adverse events such as brain swelling, hydrocephalus, and nosocomial infection was also similar in patients receiving MgSO4 or saline.In this small pilot study, MgSO4 infusion for aneurysmal SAH is feasible. On the basis of the preliminary data, a larger study recruiting approximately 800 patients is required to test for a possible neuroprotective effect of magnesium after SAH.
 

Diagnosis, Diagnostics, Immunodiagnosis & Immunodiagnostics:

14786.  Anderson DJ, Engemann JJ, Harrell LJ, Carmeli Y, Reller LB, Kaye KS. Predictors of mortality in patients with bloodstream infection due to ceftazidime-resistant Klebsiella pneumoniae. Antimicrob Agents Chemother. 2006 May;50(5):1715-20.

14787.  Arya SC, Agarwal N, Agarwal S. A laboratory-based, hospital-wide, electronic marker for nosocomial infection. Am J Clin Pathol. 2006 Jun;125(6):954.

14788.  Bootsma MC, Diekmann O, Bonten MJ. Controlling methicillin-resistant Staphylococcus aureus: quantifying the effects of interventions and rapid diagnostic testing. Proc Natl Acad Sci U S A. 2006 Apr 4;103(14):5620-5.

Therapy:

14789.  Fridkin SK, Kaufman D, Edwards JR, Shetty S, Horan T. Changing incidence of Candida bloodstream infections among NICU patients in the United States: 995-2004. Pediatrics. 2006 May;117(5):1680-7.

14790.  Livermore DM. Can beta-lactams be re-engineered to beat MRSA? Clin Microbiol Infect. 2006 Apr;12 Suppl 2:11-6.

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