Hospital-acquired Organisms Research Articles

Use of Antibiotics in Poisonous Ingestions of Corrosives and Organophosphates: A Retrospective Cohort Study.

The use of antibiotics following oral poisoning by corrosives and organophosphates is controversial. We assessed the clinical outcomes of using antibiotics in acute poisonous ingestion involving corrosives or organophosphates by conducting a retrospective cohort study of patients presenting to the emergency department following ingestion of corrosives or organophosphates who received either antibiotics or supportive care. The endpoints included clinical stability, length of stay (LOS), and mortality. Of 95 patients, 40 received antibiotics and 55 received supportive care. The median age was 2.1 and 2.7 years, respectively (p = 0.053). Bacterial growth was shown in only 2 of 28 cultures (both were respiratory), but with hospital-acquired organisms as it was shown ≥4 days post-admission. Clinical stability rates were 60% and 89.1% in the antibiotic and supportive care groups, respectively (p < 0.001). Median LOS was 3 vs. 0 days (p < 0.001), and no mortality was recorded. NG/G-tube placement was the only factor associated with clinical failure (OR, 20.97; 95% CI, 2.36-186.13). Antibiotic use was not associated with higher chances of clinical stability, which may suggest that their use was unnecessary. Clinicians are encouraged to use antibiotics wisely, and only in the presence of a clear indication of an infection. This study provides a basis for future prospective studies to confirm its findings.

Factors predicting recovery of liver function after percutaneous drainage in malignant biliary obstruction: the role of hospital-acquired biliary sepsis.

Aim of the studyProlonged cholestasis adversely affects liver function. Hepatic functional recovery is mandatory prior to any surgical or medical intervention. Serum bilirubin levels correlate well with, and are a surrogate marker for, hepatocyte function. We aimed to ascertain factors responsible for slow decline of bilirubin and delayed recovery of liver function following percutaneous drainage in malignant biliary obstruction.Material and methodsSixty-seven patients with malignant jaundice who underwent percutaneous biliary drainage (PTBD) were followed until they achieved target bilirubin ≤ 3 mg/dl. According to duration, patients were divided into early (≤ 6 weeks, n = 43) and late (> 6 weeks, n = 24) groups. Various clinical, tumour-related and procedure-related factors were analysed for their contribution to delayed recovery with the χ2 or t-test. Multi-variate logistic regression analysis was used to predict independent associations.ResultsGallbladder cancer presenting with type I block was the commonest pathology. Overall demographic, clinical, tumour characteristics and procedural details were comparable between groups. Duration of jaundice (p = 0.026), liver involvement (p = 0.041), baseline total (p = 0.001) and direct bilirubin levels (p < 0.001), positive bile cultures with hospital-acquired bacteria (p = 0.031) were significant factors on univariate analysis. Bacterial growth was significantly greater following repeated biliary manipulations. The commonest organisms were Pseudomonas and Citrobacter spp. Number of re-instrumentations, post-procedural biliary sepsis and native biliary organisms were non-contributory. No factor was significant on multivariate analysis.ConclusionsFactors directly linked to extent and duration of disease are validated as significant contributors to functional recovery after biliary drainage. Biliary sepsis with hospital-acquired organisms, especially following re-interventions is a significant modifiable risk-factor affecting bilirubin decline.

Reducing unnecessary culturing: a systems approach to evaluating urine culture ordering and collection practices among nurses in two acute care settings

BackgroundInappropriate ordering and acquisition of urine cultures leads to unnecessary treatment of asymptomatic bacteriuria (ASB). Treatment of ASB contributes to antimicrobial resistance particularly among hospital-acquired organisms. Our objective was to investigate urine culture ordering and collection practices among nurses to identify key system-level and human factor barriers and facilitators that affect optimal ordering and collection practices.MethodsWe conducted two focus groups, one with ED nurses and the other with ICU nurses. Questions were developed using the Systems Engineering Initiative for Patient Safety (SEIPS) framework. We used iterative categorization (directed content analysis followed by summative content analysis) to code and analyze the data both deductively (using SEIPS domains) and inductively (emerging themes).ResultsFactors affecting optimal urine ordering and collection included barriers at the person, process, and task levels. For ED nurses, barriers included patient factors, physician communication, reflex culture protocols, the electronic health record, urinary symptoms, and ED throughput. For ICU nurses, barriers included physician notification of urinalysis results, personal protective equipment, collection technique, patient body habitus, and Foley catheter issues.ConclusionsWe identified multiple potential process barriers to nurse adherence with evidence-based recommendations for ordering and collecting urine cultures in the ICU and ED. A systems approach to identifying barriers and facilitators can be useful to design interventions for improving urine ordering and collection practices.

Complications of Open Tibial Fracture Management: Risk Factors and Treatment.

Open tibial fractures result in high rates of complications. This study aims to elucidate the risk factors causing these complications, and suggest antimicrobial regimens based on the organisms grown in post-operative infections. Over a period of five years, 173 patients had sustained open tibial fractures and undergone operative treatment at a single institution. All surgical data was gathered retrospectively through online medical records. Thirty-one patients (17.9%) had sustained post-operative bony complications, while infective complications were reported in 37 patients (21.4%). Patients with Gustilo type III fractures were found to be more than three times as likely to sustain post-operative infective (p=0.007) or bony (p=0.015) complications, compared to Gustilo type I or II fractures. The fracture location and time taken to fixation did not significantly affect the complication rate, but results were trending towards significance. The commonest cause of infective complications were hospital-acquired organisms, such as Methicillin-resistant staphylococcus aureus (40.5%). Closer monitoring of patients sustaining high grade Gustilo open fractures, as well as antimicrobial prophylaxis for both hospital-acquired organisms and environmental contaminants, will result in the best outcome for patients. Further studies with larger sample sizes are warranted, to determine the significance of fracture location and time taken to fixation on complication rates.

Causative Pathogens, Antibiotic Sensitivity, Resistance Patterns, and Severity in a Contemporary Series of Fournier's Gangrene

To identify the causative pathogens and evaluate the antibiotic sensitivity, resistance patterns, and virulence in a contemporary series of patients with Fournier's gangrene. The medical records of 41 consecutive cases of Fournier's gangrene were evaluated. The patient demographics, causative pathogens, antibiotic sensitivity, and resistance patterns were assessed. The Fournier's gangrene severity index and length of stay were analyzed statistically to determine any differences by causative pathogen. A total of 122 pathogens were cultured. The wound cultures were polymicrobial for 34 patients (83%). Most common pathogens cultured were Bacteroides sp (43.9%), Escherichia coli (36.6%), and Prevotella sp (34.1%). E coli was resistant to fluoroquinolones and trimethoprim/sulfamethoxazole in 13.3%, and 40% of isolates respectively. The wound cultures were monomicrobial for 7 patients (17.0%). A monomicrobial isolate of methicillin-resistant Staphylococcus aureus was cultured that was susceptible to clindamycin and trimethoprim/sulfamethoxazole. Resistance to ampicillin-sulbactam was seen in Providencia sp, Klebsiella sp, E coli, and methicillin-resistant S aureus. Resistance to ceftriaxone and gentamicin was seen in methicillin-resistant S aureus and E coli, respectively. No resistance to clindamycin was demonstrated. No statistically significant difference was detected between the Fournier's gangrene severity index or length of stay and the causative pathogens. Fournier's gangrene remains a community-acquired polymicrobial infection, with anaerobic bacteria as the most common causative pathogens. Candida and methicillin-resistant S aureus are emerging causative pathogens, but methicillin-resistant S aureus remains sensitive to clindamycin and trimethoprim/sulfamethoxazole. Although resistance was demonstrated by some causative pathogens, together, the currently recommended broad-spectrum antibiotics adequately covered all pathogens. Coverage with agents such as fluconazole, vancomycin, or piperacillin-tazobactam is indicated in patients at risk of fungal or hospital-acquired organisms.

Outcome of late-onset hospital-acquired pneumonia related to causative organism

Pneumonia caused by Pseudomonas spp. has been associated with an increase in mortality in critical care patients. Previous assessments, however, have failed to compare outcome solely with other pathogens associated with hospital-acquired pneumonia (HAP). We have performed a retrospective review of all critical care patients with late-onset HAP (hospital inpatient stay >72 h at time of diagnosis) due to pure respiratory cultures of Pseudomonas spp., meticillin-resistant Staphylococcus aureus (MRSA) or non-pseudomonal Gram-negative (NPGN) organisms from 1998 to 2007. Casenote review involved assessments of illness severity, clinical pulmonary infection scoring (CPIS), critical care and hospital survival, and critical care length of stay. Out of 252 casenotes, 204 were reviewed. There were 186 treated cases of pneumonia. Ten patients had both pseudomonal and NPGN pneumonias during the same admission and two patients presented with community-acquired infections due to these organisms. These 12 patients were excluded from further analysis. Of the remaining 174 patients, 80 were infected with pseudomonas, 40 with MRSA and 54 had NPGN organisms. The three groups of patients were well-matched, with similar age, sex, CPIS scores, incidence of bacteraemia and Acute Physiology and Chronic Health Evaluation II scores at diagnosis. There were no outcome differences between the groups with respect to hospital and critical care survival and critical care length of stay. In this series, there appears to be no survival disadvantage associated with pseudomonal pneumonia when compared with other hospital-acquired organisms associated with HAP, where disease severity between the groups is similar.

The Regulation of Infection

The Regulation of Infection

Old and new antibiotics for pediatric pneumonia.

A variety of antibiotics, both parenteral and oral, are available to the clinician caring for a child with pneumonia. Although viral pathogens are the common etiologic agents causing community-acquired pneumonia, significant morbidity and mortality exists from disease caused by bacteria and atypical pneumonia agents. Treatment of nosocomial bacterial pneumonia has become particularly difficult with ever-increasing resistance documented in hospital-acquired organisms. This article discusses antibiotic therapy based on clinical presentation and based on identified pathogens, with a discussion of mechanisms of antibiotic resistance and the newer agents that have been designed to meet this continually evolving challenge.

Molecular epidemiology of infections due to Enterobacter aerogenes: identification of hospital outbreak-associated strains by molecular techniques.

Molecular techniques were used to study the epidemiology of infections due to Enterobacter aerogenes in a tertiary-care hospital. Sixty-two clinical isolates were collected from 43 patients over 3 months. Restriction endonuclease analysis (REA) of chromosomal DNA and repetitive-element polymerase chain reaction (rep-PCR) with primers based on repetitive extragenic palindromic (REP) and enterobacterial repetitive intergenic consensus (ERIC) bacterial DNA sequences were used for genomic fingerprinting. REA with HindIII or EcoRI yielded complex banding patterns that differentiated community-acquired from some hospital-acquired organisms. Less complex fingerprints were obtained with rep-PCR, which also distinguished between epidemiologically unrelated strains. More discriminatory DNA fingerprints were provided by rep-PCR when REP primers rather than ERIC primers were used. Two clusters of genomically distinct isolates from patients with recent or current exposure to the hospital environment were identified by REA and rep-PCR. Most isolates within each cluster contained characteristic plasmids, and some isolates contained additional plasmids. These results suggest colonization and infection with genotypically related strains of E. aerogenes in a nosocomial setting. Although REA and plasmid profiling are useful techniques for the epidemiological typing of E. aerogenes, genomic fingerprinting with rep-PCR may offer the advantages of ease, speed, and broad species applicability over existing molecular-typing techniques.

Infectious morbidity in extremity fractures.

To review infectious morbidity in extremity fractures, 265 patients with 280 open fractures and 573 patients with closed fractures requiring open reduction and internal fixation (ORIF) were reviewed. Among open fractures, 32 (11%) became infected. Significantly fewer infections occurred in open fractures secondary to gunshot wounds (p less than 0.01) and in the upper extremity regardless of cause (p less than 0.05). Preventive preoperative antibiotics did not appear to affect infection rates. Open fracture infections were consistently with hospital-acquired organisms, and these were consistently resistant to the preventive antibiotic employed. Closed fractures had only 18 (3%) infections after ORIF. Preoperative antibiotics did reduce infection rates compared to rates in patients with no preoperative systemic antibiotics (p less than 0.05). Pathogens in ORIF patients showed a greater preponderance of Staphylococci. In conclusion, preventive antibiotics were only effective in the prevention of infection in the ORIF patients. Open fracture patients consistently develop infections with hospital-acquired pathogens, suggesting that contamination after hospitalization rather than at the time of injury is a major factor.

Septicaemia in a teaching hospital in Kuwait — I: Incidence and aetiology

During a period of 18 months of study, blood cultures were performed on 3845 patients in hospital with clinical signs of infection. Among these, 214 (5.6%) episodes of septicaemia were diagnosed which correspond to 10.9/1000 hospital admissions. About 80% of the episodes were due to Gram-negative organisms, most common of which were Escherichia coli (19.6%), Salmonella spp (16.5%) and Klebsiella spp (15.1%). Gram-positive organisms implicated in 20% of episodes were mainly Staphylococcus aureus (9.3%) and enterococci (4.9%). Of all the septicaemias 62.0% were community-acquired with Salmonella spp. being the organism most commonly implicated. Hospital-acquired infections were mainly due to Serratia spp, Pseudomonas spp and Flavobacterium spp. The antibiotic resistance pattern of the organisms showed that hospital-acquired organisms had relatively high resistance to most antibiotics as compared with community-acquired organisms.

Infectious complications in the child with cancer. III. Prevention

BECAUSE IN Ff~CTiON is the major cause of death in the patient with cancer, considerable attention has been focused on methods for preventing'infectious complications in high-risk patients. This requires a thorough understanding of the factors that heighten the risk for serious infection, including disease- and treatment-related defects of the integumentary and mucosal physical barriers, diminished phagocytic defenses, decreased cellular and humoral immunity, and nutritional deficiency. More than 80% of the infections which occur in the patient with cancer are caused by microorganisms resident in the patient's flora; nearly half of these infecting organisms are acquired by the patient during hospitalization (the most frequent nosocomial isolates are Ps. aeruginosa, E. coli, K. pneumoniae, and C. albicans). 2~ .24 Hence colonization of the patient by new pathogenic organisms sets the stage for subsequent infectious complications (Fig. 1). Numerous hospital sources contribute to colonization, including staff-to-patient and patient-to-patient transmission, food, air, water, hospital equipment (respirators, vaporizers), and medical and surgical manipulations and procedures. In addition~ the endogenous or acquired microbial flora of the patient can be adversely perturbed by the antibiotics and chemotherapeutic agents frequently employed in cancer treatmentY ~. '-''~ Consequently, a primary objective, during the past 15 years, has been to develop methods to suppress or eliminate the endogenous microbial burden, as well as to decrease the acquisition of new hospital-acquired organisms.

Occasional notes. Please don't eat the salads.

Nearly half the infections in patients who have cancer with prolonged, severe granulocytopenia have been shown to be caused by hospital-acquired organisms that have colonized the alimentary canal.1...

Support systems for the patient with cancer: future prospects.

Bleeding and infection are the usual proximate causes of morbidity and mortality in patients with hematologic malignancy and many solid tumors. The most important cause of bleeding is thrombocytopenia. The use of immunologically matched platelets has rendered this complication less frequent. Host defenses against infection are often compromised unavoidably as a function of the primary disease and its therapy. However, it is important to note that many infections are caused by hospital-acquired organisms; a significant number of infections can be avoided with meticulous attention to possible breaches of the host barriers against invasion. Diagnosis and treatment of infection in the altered host are urgent and demanding, since the median survival with inappropriate therapy of bacterial sepsis is less than 3 days. Newer diagnostic techniques, such as the gallium scan, are helpful, as are antimicrobial combinations used empirically. Experimental approaches to the prevention of infection include antibacterial vaccines, the use of laminar air-flow isolation, and transplantation of bone marrow. Experimental approaches to the therapy of infection include leukocyte transfusion and the use of transfer factor. A discussion of supportive care must also include consideration of the psychosocial concomitants of the cancer process, particularly those factors in the doctor-patient relationship which promote anxiety in the physician to the end that his support of the patient is not effective.

SOURCES OF PSEUDOMONAS ÆRUGINOSA INFECTION IN A RESPIRATORY/SURGICAL INTENSIVE-THERAPY UNIT

Monitoring of pseudomonas pyocine types from 640 patients and their environment was undertaken in a respiratory/surgical intensive-therapy unit (R.S.I.T.U.) during a nineteen-month period. Forty of fifty-six sputum or throat isolates of pseudomonas were clearly hospital acquired and at least 10 of the 16 patients who had Pseudomonas œruginosa on first culture were suspected of having hospital-acquired organisms. Pyocine types 1 and 10 were the "resident" strains; type-10 outbreaks occurred in clusters. Both types were regularly cultured from only one environmental source (the sinks), even during one to two week intervals during which no patients in the R.S.I.T.U. were colonised with pseudomonas. It is suggested that the sinks provide reservoirs of pseudomonas infection and that the hands of personnel are the vehicles of transmission.