Crude Mortality Rate For Patients Research Articles

Vliv pandemie covidu-19 na akutní pankreatitidu v České republice – pilotní data studie PANACOTA (PANcreatitis Acuta in COvid Time Analysis)

Summary: Introduction: The COVID-19 pandemic had a significant impact on health care. Previous studies point to a possible negative impact of COVID-19 infection on the development and severity of acute pancreatitis. The aim of this study is to analyze the impact of the COVID-19 pandemic on the epidemiology, treatment and prognosis of acute pancreatitis at the population level. Methods: Using data from the National Registry of Reimbursed Health Services (NRRHS) parameters of hospital admissions for acute pancreatitis, the provided health care and treatment outcomes in the pandemic period (2020 and 2021) with previous years (2010–2019) were compared. Results: The incidence during the pandemic was not significantly different from the previous period: 67 vs. 63 per 100,000 population. Hospitalizations for acute pancreatitis in each month of 2020 and 2021 did not correlate with the number of COVID-19 positive patients. The overall mortality rates for acute pancreatitis before and during the pandemic were almost identical – at 3.8% and 3.9%, respectively. There was a trend towards a decrease in the number of surgical procedures, a gradual decrease in ERCPs and an increase in endoscopic drainages throughout the 2010–2021 period. The crude mortality rate of patients hospitalized for COVID-19 and concomitant acute pancreatitis was 14.2% and these patients were operated in 4.7%. Conclusions: Based on pilot population data, the COVID-19 pandemic did not have an impact on the incidence of acute pancreatitis in the Czech Republic. A more severe course and prognosis of the disease was associated with near-term COVID-19 positivity. More frequent indication of surgical and other interventions for acute pancreatitis in COVID-19 positive individuals may have been related to the disruption of standard quality and availability of care. Key words: acute pancreatitis – COVID-19 – epidemiology – endoscopic drainage – surgery – complications

SG-APSIC1157: The attributable mortality and excess length of stay associated with third-generation cephalosporin-resistant Enterobacterales bloodstream infections—A prospective cohort study in Suva, Fiji

Objectives: Although antimicrobial resistance (AMR) disproportionately affects low- and middle-income countries (LMICs), primary clinical data on AMR burden from LMICs are lacking, particularly from the Pacific Islands. We adapted recent World Health Organization methodology to measure the impact of third-generation cephalosporin (3GC) resistance on mortality and excess length of hospital stay among inpatients with Enterobacterales bloodstream infection (BSI) in Fiji. Methods: We conducted a prospective cohort study of inpatients with Enterobacterales BSIs at Colonial War Memorial Hospital in Suva. We collected demographic, clinical, and microbiological data, and we stored bacterial isolates for confirmatory testing and molecular genomics in Melbourne, Australia. We employed cause-specific Cox proportional hazards models to estimate the effect of 3GC-resistance on hazard of in-hospital mortality and discharge alive (competing outcomes), and we used multistate modelling to estimate the excess length of hospital stay associated with 3GCR. Results: From July 2020 to February 2021, we identified 162 consecutive Enterobacterales BSIs, and 66 (40.7%) were 3GC resistant. The crude mortality rates for patients with 3GC-susecptible and 3GC-resistant BSIs were 16.7% (16 of 96) and 30.3% (20 of 66), respectively. Also, 3GC resistance was not associated with either in-hospital mortality (aHR, 1.67; 95% CI, 0.80–3.49) or discharge alive (aHR, 0.75; 95% CI, 0.50–1.12). However, patient comorbidities and acuity of illness were associated with in-hospital mortality. Furthermore, 3GC-resistance was associated with an increased length of stay of 2.6 days (95% CI, 2.5–2.8). Overall, 3GC-resistance was more common among patients with hospital-associated than community-acquired infection, but genomics did not identify clonal transmission. Conclusions: Among patients with Enterobacterales BSIs, mortality was relatively high, and 3GC resistance was common. Also, 3GC resistance was associated with increased hospital length of stay but not with in-hospital mortality after adjusting for potential confounders. Accurate estimates of the burden of AMR are important, especially from LMICs. Such knowledge can inform policy decisions, guide allocation of limited resources, and assist the evaluation of future interventions to address AMR.

Outcomes among Hospitalized Chronic Kidney Disease Patients with COVID-19.

Patients with CKD ha ve impaired immunity, increased risk of infection-related mortality, and worsened COVID-19 outcomes. However, data comparing nondialysis CKD and ESKD are sparse. Patients with COVID-19 admitted to three hospitals in the New York area, between March 2 and August 27, 2020, were retrospectively studied using electronic health records. Patients were classified as those without CKD, those with nondialysis CKD, and those with ESKD, with outcomes including hospital mortality, ICU admission, and mortality rates. Of 3905 patients, 588 (15%) had nondialysis CKD and 128 (3%) had ESKD. The nondialysis CKD and ESKD groups had a greater prevalence of comorbidities and higher admission D-dimer levels, whereas patients with ESKD had lower C-reactive protein levels at admission. ICU admission rates were similar across all three groups (23%-25%). The overall, unadjusted hospital mortality was 25%, and the mortality was 24% for those without CKD, 34% for those with nondialysis CKD, and 27% for those with ESKD. Among patients in the ICU, mortality was 56%, 64%, and 56%, respectively. Although patients with nondialysis CKD had higher odds of overall mortality versus those without CKD in univariate analysis (OR, 1.58; 95% CI, 1.31 to 1.91), this was no longer significant in fully adjusted models (OR, 1.11; 95% CI, 0.88 to 1.40). Also, ESKD status did not associate with a higher risk of mortality compared with non-CKD in adjusted analyses, but did have reduced mortality when compared with nondialysis CKD (OR, 0.57; 95% CI, 0.33 to 0.95). Mortality rates declined precipitously after the first 2 months of the pandemic, from 26% to 14%, which was reflected in all three subgroups. In a diverse cohort of patients with COVID-19, we observed higher crude mortality rates for patients with nondialysis CKD and, to a lesser extent, ESKD, which were not significant after risk adjustment. Moreover, patients with ESKD appear to have better outcom es than those with nondialysis CKD.

Prolonged length of stay in the emergency department and increased risk of hospital mortality in patients with sepsis requiring ICU admission

Background and objectivesDelayed patient admission to the intensive care unit (ICU) from the ED is common in China. Patients with severe sepsis or septic shock requiring ICU admission are in...

Micafungin Breakthrough Fungemia in Patients with Hematological Disorders.

Limited data are available on micafungin breakthrough fungemia (MBF), fungemia that develops on administration of micafungin, in patients with hematological disorders. We reviewed medical and microbiological records of patients with hematological disorders who developed MBF between January 2008 and June 2015. A total of 39 patients with MBF were identified, and Candida (30 strains) and non-Candida (9 strains) fungal species were recognized as causative strains. Among 35 stored strains, Candida parapsilosis (14 strains), Trichosporon asahii (7 strains), Candida glabrata (5 strains), and other fungal species (9 strains) were identified by sequencing. Neutropenia was identified as an independent predictor of non-Candida fungemia (P = 0.023). T. asahii was the most common causative strain (7/19) during neutropenia. The 14-day crude mortality rate of patients treated with early micafungin change (EMC) to other antifungal agents was lower than that of the patients not treated with EMC (14% versus 43%, P = 0.044). Most of the stored causative Candida strains were susceptible (80%) or showed wild-type susceptibility (72%) to micafungin. The MICs of voriconazole for T. asahii were low (range, 0.015 to 0.12 μg/ml), whereas the MICs of amphotericin B for T. asahii were high (range, 2 to 4 μg/ml). MBF caused by non-Candida fungus should be considered, especially in patients with neutropenia. EMC could improve early mortality. Based on epidemiology and drug susceptibility profiling, empirical voriconazole-containing therapy might be suitable for treating MBF during neutropenia to cover for T. asahii.

Bacteraemia due to extensively drug-resistant Pseudomonas aeruginosa sequence type 235 high-risk clone: Facing the perfect storm

Predictors of mortality and the impact of multidrug resistance and virulence on patients with Pseudomonas aeruginosa (PA) bacteraemia were evaluated. Patients with PA bacteraemia in a 12-month period were retrospectively analysed. Carbapenemase production, molecular typing and identification of virulence factor ExoU were carried out. The activity of ceftolozane-tazobactam and ceftazidime-avibactam was also investigated. The primary endpoint was 30-day crude mortality. Of 64 patients with bacteraemia, 24 (37.5%) were caused by extensively drug-resistant PA (XDR-PA): 10 (41.7%) cases involved the VIM-2 carbapenemase-producing ST175 clone, 11 (45.8%) the GES-5 carbapenemase-producing ST235 clone, and 3 (12.5%) were non-carbapenemase producers. The exoU genotype was detected in all ST235 strains and in 6 (15%) of the non-XDR isolates. Ceftazidime-avibactam (58.3%) showed greater activity than ceftolozane-tazobactam (12.5%) against XDR-PA isolates, particularly in GES-5 producers (100%). The 30-day crude mortality rate in patients with XDR-PA bacteraemia was higher than in cases caused by susceptible strains (62.5% vs. 30%; P=0.02). Multivariate analysis showed that independent risk factors associated with 30-day crude mortality were Pitt score ≥2 (OR, 42.31; 95% CI, 4.88-366.7; P=0.001) and respiratory source of bacteraemia (OR, 49.13; 95% CI 3.89-620.5; P=0.003). Stratified analysis adjusting for respiratory source revealed a non-significant trend towards higher mortality in patients with bacteraemia caused by the ST235 clone and exoU-producing isolates. These data support the notion that the XDR phenotype associated with the GES-5 carbapenemase-producing ST235 clone and the exoU-positive genotype adversely affects the outcome of patients with PA bacteraemia, particularly those with respiratory tract infections and a severe clinical presentation.

Surveillance of Healthcare-Associated Infections Rates in Hematology-Oncology Patients

Background: Healthcare-associated infections (HAIs) consist of a major cause of morbidity and mortality among patients with hematologic malignancies, resulting in high length of stay and healthcare costs. The aim of this study was to assess the HAIs rates in adult hematology-oncology patients.Patients and Methods: A prospective surveillance study was performed in a hematology-oncology unit in Athens, Greece. All patients who remained for ≥ 48 hours were studied. A standardized surveillance system based on the National Healthcare Safety Network of the Centers for Disease Control and Prevention was implemented.Results: During 1,156 patient-days, 16 of 85 patients acquired 20 HAIs resulting in an overall rate of 18.8% of patients or 17.3 HAIs per 1,000 patient-days. FUO rate was 42.5 per 1,000 patient-days with neutropenia. Most of HAIs was laboratory confirmed (80%) than clinically documented (20%). Central line-associated bloodstream infection was the most commonly encountered type of infection, accounting for 25% of all HAIs, followed by soft tissue infections (20%). The rates of neutropenia, blood transfusion and presence of central venous catheter were significantly greater among patients with HAI, compared with patients without HAI (p<0.05). The crude mortality rate for patients with and without HAI was 12.5% and 2.9%, respectively (p=0.234).The mean length of stay was statistically longer for patients with HAI compared with patients without HAI (29.6 ± 28.5 vs. 9.8 ± 6.8 days, p<0.001). Gram-negative bacteria were the most prevalent pathogens (73.3%).Conclusions: Our findings highlight the problem of HAIs in hematology-oncology patients and emphasize the importance of a comprehensive education program focused on evidence-based approaches for all healthcare workers and continuing active surveillance program, which will contribute to reducing the consequences of HAIs and improving patient safety.

Bloodstream infections caused by multi-drug resistant Proteus mirabilis: Epidemiology, risk factors and impact of multi-drug resistance

ABSTRACTBackground The prevalence of antimicrobial co-resistance among ESBL-producing Enterobactereaceae is extremely high in Israel. Multidrug-resistant Proteus mirabilis strains (MDR-PM), resistant to almost all antibiotic classes have been described. The aim was to determine the risk factors for bloodstream infections caused by MDR-PM and clinical outcomes. Methods A retrospective case-control study. Adult patients with PM bacteremia during 7 years were identified retrospectively and their files reviewed for demographics, underlying diseases, Charlson Comorbidity Index, treatment and outcome. Results One hundred and eighty patients with PM-bloodstream infection (BSI) were included; 90 cases with MDR-PM and 90 controls with sensitive PM (S-PM). Compared to controls, cases more frequently were from nursing homes, had recurrent hospital admissions in the past year and received antibiotic therapy in the previous 3 months, were bedridden and suffered from peripheral vascular disease and peptic ulcer disease (p < 0.001). Two-thirds of the MDR-PM isolates were ESBL-producers vs 4.4% of S-PM isolates (p < 0.001, OR = 47.6, 95% CI = 15.9–142.6). In-hospital crude mortality rate of patients with MDR-PM BSI was 37.7% vs 23.3% in those with S-PM BSI (p = 0.0359, OR = 2, 95% CI = 1.4–3.81). Conclusions PM bacteremia in elderly and functionally-dependent patients is likely to be caused by nearly pan-resistant PM strains in the institution; 51.8% of the patients received inappropriate empiric antibiotic treatment. The crude mortality rate of patients with MDR-PM BSI was significantly higher than that of patients with S-PM BSI.

Multi-drug resistant gram negative infections and use of intravenous polymyxin B in critically ill children of developing country: retrospective cohort study.

BackgroundPatients in pediatric intensive care Units (PICU) are susceptible to infections with antibiotic resistant organisms which increase the morbidity, mortality and cost of care.To describe the clinical characteristics and mortality in patients with Multi-Drug Resistant (MDR) gram negative organisms. We also report safety of Polymyxin B use in these patients.MethodsFiles of patients admitted in PICU of Aga Khan University Hospital, from January 2010 to December 2011, one month to 15 years of age were reviewed. Demographic and clinical features of patients with MDR gram negative infections, antibiotic susceptibility pattern of isolates, discharge disposition and adverse effects of Polymyxin B were recorded.ResultsA total of 44.8/1000(36/803) admitted patients developed MDR gram negative infections, of which 47.2%(17/36) were male, with mean age of 3.4 yrs(+/−4.16). Acinetobacter Species (25.5%) was the most frequently isolated MDR organisms followed by Klebsiella Pneumoniae (17%). Sensitivity of isolates was 100% to Polymyxin B, followed by Imipenem (50%), and piperacillin/tazobactem (45%). The crude mortality rate of patients with MDR gram negative infections was 44.4% (16/36). Fourteen of 36 patients received Polymyxin B and 57.1%; (8/14) of them were cured. Nephrotoxicity was observed in 21.4% (3/14) cases, none of the patients showed signs of neuropathy.ConclusionOur study highlights high rates of Carbapenem resistant gram negative isolates, leading to increasing use of Polymyxin B as the only drug to combat against these critically ill children. Therefore, we emphasizeon Stewardship of Antibiotics and continuous surveillance system as strategies in overall management of these critically ill children.

Absence of interaction of diabetes mellitus with chronic kidney disease on mortality in acute heart failure

Objectives: To evaluate how chronic kidney disease (CKD) and diabetes mellitus (DM) influence in-hospital mortality in patients urgently admitted for acute heart failure (HF). Methods: We used data from the Spanish “Minimum Basic Data Set” for 2006–2007 to evaluate clinical differences and crude mortality rates for patients having versus non-having CKD or DM. We tested pre-specified predictive factors of in-hospital mortality in a multivariate logistic regression model, which included age, sex, CKD, DM, acute respiratory failure, a modified Charlson Comorbidity Index—excluding CKD/DM- and a CKD × DM-interaction variable. p Values < 0.05 were considered significant. Main findings: A total of 275,176 episodes of acute HF were analyzed (47.9% male, mean age 76.2 ± 12.8 years). CKD patients (N = 25,174, 9.1%) were older (78.4 ± 10.1 vs. 76.0 ± 13.1 years; p < 0.001) and more frequently had coexisting medical conditions. DM patients (N = 88,994, 32.3%) more often had vascular risk factors and CKD (11.4% vs. 8.1%; p < 0.001). Overall in-hospital mortality rate for admitted HF patients was 10.4%. Mortality was lower for DM versus non-DM patients (9.2% vs. 11.0%; p < 0.001), but higher for CKD versus non-CKD patients (14.1% vs. 10.0%; p < 0.001). No interaction effect was found between CKD and DM on survival for a HF episode (odds ratio; OR = 1.01, 95% CI: 0.91–1.10; p for interaction = 0.73). DM remained protective (OR = 0.85, 95% CI: 0.82–0.87; p < 0.001), while CKD was associated with increased mortality (OR = 1.46, 95% CI: 1.39–1.53; p < 0.001). Conclusions: In patients urgently admitted for HF, the association of CKD with higher in-hospital mortality was homogeneous irrespectively of the absence or presence of DM.

Post-discharge mortality in patients hospitalized with MRSA infection and/or colonization

Methicillin-resistant Staphylococcus aureus (MRSA) infection is known to increase in-hospital mortality, but little is known about its association with long-term health. Two hundred and thirty-seven deaths occurred among 707 patients with MRSA infection at the time of hospitalization and/or nasal colonization followed for almost 4 years after discharge from the Atlanta Veterans Affairs Medical Center, USA. The crude mortality rate in patients with an infection and colonization (23·57/100 person-years) was significantly higher than the rate in patients with only colonization (15·67/100 person-years, P = 0·037). MRSA infection, hospitalization within past 6 months, and histories of cancer or haemodialysis were independent risk factors. Adjusted mortality rates in patients with infection were almost twice as high compared to patients who were only colonized: patients infected and colonized [hazard ratio (HR) 1·93, 95% confidence interval (CI) 1·31-2·84]; patients infected but not colonized (HR 1·96, 95% CI 1·22-3·17). Surviving MRSA infection adversely affects long-term mortality, underscoring the importance of infection control in healthcare settings.

Clinical characteristics of bacteraemia caused by extended-spectrum β-lactamase-producing Enterobacteriaceae in the era of CTX-M-type and KPC-type β-lactamases

A multicentre, case-control study was conducted to assess risk factors and patient outcomes of bacteraemia caused by Enterobacteriaceae producing extended-spectrum β-lactamases (ESBLs) and Klebsiella pneumoniae carbapenemases (KPCs). One hundred and five and 20 patients with bacteraemia caused by ESBL-producing and KPC-producing organisms were matched to controls who had bacteraemia caused by non-ESBL/KPC-producing organisms, respectively. Independent risk factors for ESBL production included admission from a nursing home (OR 4.64; 95% CI 2.64–8.16), chronic renal failure (OR 2.09; 95% CI 1.11–3.92), the presence of a gastrostomy tube (OR 3.36; 95% CI 1.38–8.18), length of hospital stay before infection (OR 1.02; 95% CI 1.01–1.03), transplant receipt (OR 2.48; 95% CI 1.24–4.95), and receipt of antibiotics with Gram-negative activity in the preceding 30 days (OR 1.76; 95% CI 1.00–3.08). Twenty-eight-day crude mortality rates for patients infected with ESBL-producing or KPC-producing organisms and controls were 29.1% (34/117) and 19.5% (53/272), respectively (OR 1.70; 95% CI 1.04–2.80). On multivariate analysis, inadequate empirical therapy (OR 2.26; 95% CI 1.18–4.34), onset of bacteraemia while in the intensive-care unit (OR 2.74; 95% CI 1.47–5.11), Apache II score (OR 1.17; 95% CI 1.12–1.23) and malignancy (OR 2.66; 95% CI 1.31–5.41) were independent risk factors for mortality. CTX-M was the most common ESBL type in Escherichia coli, whereas SHV predominated in Klebsiella spp. and Enterobacter spp.

Clostridium difficile colitis: A retrospective study of incidence and severity before and after institution of an alcohol-based hand rub policy

Clostridium difficile-associated diarrhea is a leading cause of hospital-acquired diarrhea. We sought to determine whether the institution of a hospital-wide alcohol-based hand rub (ABHR) policy was associated with an increase in the incidence and/or severity of health care facility-onset, health care facility-associated C difficile diarrhea (CDAD). We used a retrospective chart review analysis to compare incidence rates of CDAD before and after implementation of the ABHR policy. We also compared rates of sepsis, colectomy, and death in patients with CDAD before and after implementation of the ABHR policy. The incidence rate of CDAD was 3.98 per 10,000 patient-days after implementation of the ABHR policy, compared with 4.96 per 10,000 patient-days before implementation (P = .0036). The crude mortality rate in patients diagnosed with CDAD was 10.7% after implementation, compared with 13.3% before implementation (P = .275). The rate of sepsis in patients diagnosed with CDAD was 19.6% after implementation, compared with 5.2% before implementation (P < .0001). Our data provide no evidence of an increased CDAD rate after implementation of an ABHR policy at our institution. The rate of sepsis in patients diagnosed with CDAD did rise, indicating increased severity of illness in patients with C difficile infection.

Consensus statement on the management of invasive candidiasis in Intensive Care Units in the Asia-Pacific Region

Invasive candidiasis has emerged as an important nosocomial infection, especially in critically ill patients. The incidence of candidaemia in Intensive Care Units (ICUs) is 5- to 10-fold higher than in the entire hospital and the crude mortality rate of patients with candidaemia is between 35% and 60%. Candida albicans remains the predominant cause of invasive candidiasis in ICUs, followed by Candida tropicalis, Candida glabrata and Candida parapsilosis. Invasive isolates of Candida spp. remain highly susceptible to fluconazole (>90% susceptible), although among Asia-Pacific countries the susceptibility rate of C. glabrata to fluconazole varies widely from 22% to 72%. Early diagnosis and prompt initiation of antifungal therapy are crucial for the effective treatment of invasive candidiasis. However, invasive candidiasis is difficult to diagnose owing to its non-specific clinical features, and delayed therapy is a major contributor to poor outcomes. Combining clinical risk factors with Candida colonisation parameters appears promising for guiding early interventions. Because of considerable regional variability, local epidemiological knowledge is critical in the effective management of invasive candidiasis among ICU patients in Asia-Pacific.

Nosocomial infections in pediatric cardiovascular surgery patients: A 4-year survey

To determine the prevalence, characteristics, and risk factors for nosocomial infections (NIs) in children postcardiac surgery and hospitalized in a pediatric intensive care unit (PICU). Case control study. PICU of a tertiary care university-affiliated medical center. Between January 1, 1999 and December 31, 2002, 356 children underwent cardiac surgery and were admitted to the PICU (381 admissions). There were 146 episodes (91 patients) of NI according to the Centers for Disease Control and Prevention criteria. The control group (92 patients) was drawn as a random sample from admissions with no evidence of NI. Data retrieved from medical records included demographic information, type of operation, complexity score, extrinsic risk factors (invasive devices, postoperative complications, etc.), specific pathogens, therapeutic interventions, and outcome. There were 146 episodes of NI during 381 admissions, yielding a nosocomial infection ratio of 38.3%, and a prevalence of PICU-acquired infection of 24.4% (93 admissions with NI out of a total of 381 admissions). The most common NI sites were the bloodstream and the lower respiratory tract (65.8% and 16.4%, respectively). The main causative organisms were Coagulase negative Staphylococcus, Klebsiella pneumonia, and Candida spp. (18.8%, 16.7%, and 15%, respectively). Multivariate analysis revealed the following risk factors for NI: age < 2 months, congenital malformations, post operative complications, and open-chest procedure. The crude mortality rate for patients with NI was 23.7%, compared with 2.2% for patients without NI (p < 0.001). Predictors for mortality in patients with NI were post operative complications, open-chest procedure, sepsis, and urinary tract infection. Our results draw attention to the importance of NI and their influence on survival in pediatric patients undergoing cardiac surgery. Prevention and control measures may reduce these infections and subsequently reduce morbidity and mortality in this vulnerable population.

Risk-factors and predictors of mortality in patients colonised with vancomycin-resistant enterococci

Vancomycin-resistant enterococci (VRE) have emerged as significant nosocomial pathogens. A hospital-wide prevalence study was performed to identify cases with VRE faecal colonisation. A case-control study using two randomly selected VRE-negative controls for each positive case was performed to assess risk-factors for VRE colonisation by univariate and multivariate analysis. VRE faecal colonisation was documented in 53 (14.3%) of 370 patients screened. Previous exposure to anti-anaerobic agents, as well as quinolones, was associated with VRE colonisation (p <0.05). The presence of an invasive device (OR 4.8, p 0.003) and the duration of any antimicrobial treatment before VRE isolation (OR 1.2, p <0.001) predicted VRE colonisation in multivariate models. The crude mortality rate for patients with VRE colonisation was 24.5%, but VRE colonisation was not an independent predictor of mortality in these patients. These results suggest that an active surveillance programme focusing on specific patient groups may help in the identification of VRE-colonised patients. Promptly implemented infection control strategies targeting these groups should help to combat the rising incidence of VRE.

Adjunctive immunotherapy in combination with lipid-associated amphotericin B for the treatment of invasive candidiasis

Introduction: Nosocomial bloodstream infections caused by Candida spp result in increased morbidity and mortality in hospitalized patients, especially those in the intensive care unit [1]. Despite the availability of the less toxic lipidassociated amphotericin B formulations, as well as the newer triazoles and echinocandins, the outcome of therapy remains poor. Crude mortality rates for patients with candidemia range from 30% to 60%; and mortality rates directly attributable to candidemia range between 10% and 30% [2,3]. In order to improve clinical outcome, combination therapy with conventional antifungal agents for the treatment of candidemic patients has recently been evaluated [4]. Because patients with serious candidal infections are frequently immunocompromised, combining adjunctive immunotherapy with conventional antifungal agents is also under study [5].

Device-Associated Nosocomial Infections in 55 Intensive Care Units of 8 Developing Countries

Health care-associated infections from invasive medical devices in the intensive care unit (ICU) are a major threat to patient safety. Most published studies of ICU-acquired infections have come from industrialized western countries. In a Centers for Disease Control and Prevention (CDC) National Nosocomial Infections Surveillance (NNIS) System report, the U.S. pooled mean rates of central venous catheter (CVC)-related bloodstream infections, ventilator-associated pneumonia, and catheter-associated urinary tract infections were 4.0 per 1000 CVC days, 5.4 per 1000 mechanical ventilator days, and 3.9 per Foley catheter days, respectively. To ascertain the incidence of device-associated infections in the ICUs of developing countries. Multicenter, prospective cohort surveillance of device-associated infection by using the CDC NNIS System definitions. 55 ICUs of 46 hospitals in Argentina, Brazil, Colombia, India, Mexico, Morocco, Peru, and Turkey that are members of the International Nosocomial Infection Control Consortium (INICC). Rates of device-associated infection per 100 patients and per 1000 device days. During 2002-2005, 21,069 patients who were hospitalized in ICUs for an aggregate 137,740 days acquired 3095 device-associated infections for an overall rate of 14.7% or 22.5 infections per 1000 ICU days. Ventilator-associated pneumonia posed the greatest risk (41% of all device-associated infections or 24.1 cases [range, 10.0 to 52.7 cases] per 1000 ventilator days), followed by CVC-related bloodstream infections (30% of all device-associated infections or 12.5 cases [range, 7.8 to 18.5 cases] per 1000 catheter days) and catheter-associated urinary tract infections (29% of all device-associated infections or 8.9 cases [range, 1.7 to 12.8 cases] per 1000 catheter days). Notably, 84% of Staphylococcus aureus infections were caused by methicillin-resistant strains, 51% of Enterobacteriaceae isolates were resistant to ceftriaxone, and 59% of Pseudomonas aeruginosa isolates were resistant to fluoroquinolones. The crude mortality rate for patients with device-associated infections ranged from 35.2% (for CVC-associated bloodstream infection) to 44.9% (for ventilator-associated pneumonia). These initial data are not adequate to represent any entire country, and likely variations in the efficiency of surveillance and institutional resources may have affected the rates that were detected. Device-associated infections in the ICUs of these developing countries pose greater threats to patient safety than in U.S. ICUs. Active infection control programs that perform surveillance of infection and implement guidelines for prevention can improve patient safety and must become a priority in every country.

Risk factors for acquisition of vancomycin-resistant enterococci among hematology-oncology patients

The incidence of VRE has increased dramatically and hematology-oncology patients are at high risk for acquisition of colonization and development of infection. Therefore, we performed a prospective cohort study to determine risk factors for VRE acquisition among hematology-oncology patients. Patients admitted to a single unit at Northwestern Memorial Hospital, which was predominantly comprised of patients with hematologic malignancies and recipients of hematopoietic stem cell transplants, were enrolled. Rectal or perianal swabs were obtained on hospital day 1, 4, 7 and then weekly thereafter. Data were collected by medical record review. We evaluated 155 study patients; 12 patients (7.7%) converted from VRE negative to positive. Among these 12 patients, 3 were positive on prior admissions, and 9 acquired VRE during the study. The median time to acquisition was 9 days. The median length of stay was significantly longer for patients with VRE compared to those who were VRE negative (31 vs. 6 days, P < 0.01). Patients with VRE were significantly more likely than those without VRE to have had an ICU admission within 3 months (P = 0.003), been admitted from an acute care facility (P = 0.001), or to have received amikacin (P = 0.02). Antimicrobials were commonly prescribed to all of the patients as 87% received an antimicrobial prior to their first swab. The crude mortality rate for patients with VRE was 67%. Prolonged length of stay, prior hospitalization, previous ICU admission and receipt of amikacin were risk factors associated with VRE acquisition among hematology-oncology patients. Mortality among these patients was high, due to serious underlying disease.

Renal replacement therapy for patients with diabetes mellitus in Hong Kong

Diabetes mellitus is becoming the most common cause of end-stage renal failure in Hong Kong. This review is based on data from the Hong Kong Renal Registry from 1995 through 2000. As of March 31, 2000, a total of 1026 patients with diabetes mellitus were on renal replacement therapy. A total of 809 patients had diabetic nephropathy as primary disease and 217 had diabetes mellitus as comorbidity. The prevalence of renal replacement therapy for patients with diabetes mellitus was 151 per million population. For the year ending March 31, 2000, there were 342 new patients with diabetes mellitus requiring renal replacement therapy. Of all the patients on renal replacement therapy, 23% were diabetic. The patients with diabetes mellitus were older (median age, 63 years), and had a higher incidence of hypertension (85%), ischemic heart disease (24%), cerebrovascular disease (9%), and peripheral vascular disease (3%). The modes of renal replacement therapy for patients with diabetes mellitus were peritoneal dialysis (81%), hemodialysis (9%), and transplant (10%). The annual crude mortality rate of patients with diabetes mellitus was 16% (peritoneal dialysis, 17%; hemodialysis, 18%; transplant, 1%) compared with 6% for patients without diabetes mellitus (peritoneal dialysis, 8%; hemodialysis, 12%; transplant, 1%). The major causes of death were cardiovascular disease (33%), infection (28%), and cerebrovascular event (8%). The 1-and 5-year survival rates of dibetic patient were 89% and 32% for peritoneal dialysis, 73% and 26% for hemodialysis, and 94% and 87% for transplant, respectively. The 1-and 5-year graft survival rates were 88% and 82% (death not censored), and 91% and 91% (death censored), respectively.