Nosocomial Infection
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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. |
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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. |
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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. |
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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. |
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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.
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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. 14791. Sanchez-Velazquez LD, Ponce de Leon Rosales S, Rangel Frausto MS. The burden of nosocomial infection in the intensive care unit: Effects on organ failure, mortality and costs. A nested case-control study. Arch Med Res. 2006 Apr;37(3):370-5. |