Hospital Unit Research Articles

The effect of using low dose norepinephrine before hypotensive resuscitation in hemorrhagic shock; a randomized controlled trial

Background & Objectives: Hemorrhagic shock is not a very rare occurrence in big hospitals. It might be encountered in the emergency room (ER) or in the operating rooms (OR). A rapid response and systematic management will save the life of the victim. The objective of this research was to investigate the impact of a low dose of norepinephrine (NE) administered prior to the initiation of hypotensive resuscitation in patients with hemorrhagic shock. Methodology: This randomized controlled trial was conducted on 200 participants, at least 18 years old, classified as severely traumatized and had significant hemorrhage with mean arterial pressure ranging from 65 to 75 mmHg. We divided the patients into two equal groups. Group I received a low dose of NE (< 0.3 µg/kg/min) concurrently with resuscitation fluids. Group II received resuscitative fluids only. If the resuscitative fluids failed to keep mean arterial pressure (MAP) > 65 mmHg, the patient was progressively administered NE even with high doses (0.05 to more than 0.3 µg/kg/min). The primary outcome was 24-hour mortality. In-hospital mortality, incidence of acute kidney injury (AKI), and duration of hospital and intensive care unit (ICU) stay constituted the secondary outcomes. Results: Group I had lower 24-hour mortality compared to Group II (3% vs 13%; P < 0.05). Compared to Group II, Group I needed reduced amount of fluid resuscitation within 24 h, had lower serum lactate levels at 6 and 12 h, and lower serum creatinine at 6, 12, and 18 h (P < 0.001). Group I had a lower incidence of mechanical ventilation (13% vs 27%), hospital and ICU stays, and in-hospital mortality (9% vs 21%) (P < 0.05). There was a lack of disparity seen in the incidence of AKI and duration of mechanical ventilation. Conclusion: Low-dose norepinephrine infusion during the early period of hypotensive resuscitation reduces resuscitative fluid requirement, improves tissue perfusion, preserves renal function, and lowers mortality in hemorrhagic shock patients. Abbreviations: AKI - acute kidney injury; APACHE III - Acute Physiology And Chronic Health Evaluation III; HS - hemorrhagic shock; ICU - intensive care unit; MAP - mean arterial pressure; NE - Norepinephrine Keywords: Hemorrhagic Shock; Hypotensive Resuscitation; Norepinephrine; Fluid Therapy; Renal Protection; Mortality; Low Dose Citation: Mohamed RM, Anwar AG, Eid AA. The effect of using low dose norepinephrine before hypotensive resuscitation in hemorrhagic shock; a randomized controlled trial. Anaesth. pain intensive care 2024;28(5):914−921; DOI: 10.35975/apic.v28i5.2560 Received: April 17, 2024; Reviewed: August 03, 2024; Accepted: September 04, 2024

Efficacy and Safety of Andexanet Alfa Versus Four Factor Prothrombin Complex Concentrate for Emergent Reversal of Factor Xa Inhibitor Associated Intracranial Hemorrhage: A Systematic Review and Meta-Analysis.

Factor Xa inhibitors (FXaI) are increasingly used for anticoagulation therapy, yet their association with intracranial hemorrhage poses a significant challenge. Although andexanet alfa (AA) and four-factor prothrombin complex concentrate (4F-PCC) have shown promise in reversing FXaI effects, their comparative efficacy and safety remain uncertain. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted a literature search on electronic databases to obtain the relevant studies until May 16, 2024. Our primary outcomes were successful anticoagulation reversal, overall mortality (including 30-day and in-hospital mortality), and thromboembolic events. Secondary outcomes were length of hospital and intensive care unit stay and hematoma volume expansion. Data were pooled using a random-effects model. We included 16 eligible studies with a total of 2,977 patients. A statistically significant improvement in hemostatic efficacy rates was in favor of the AA group (risk ratio [RR] 1.10, 95% confidence interval [CI] 1.01-1.20, P = 0.02). Lower overall mortality rates were found in the AA group (RR 0.67, 95% CI 0.51-0.88, P = 0.004). However, no difference was found in 30-day mortality rates (RR 0.82, 95% CI 0.58-1.16, P = 0.26). In terms of thromboembolic events, more events were found in the AA group (RR 1.47, 95% CI 1.01-2.15, P = 0.046). AA was associated with a longer duration of hospital stay compared to 4F-PCC (mean difference [MD] 0.64, 95% CI 0.07-1.22, P = 0.03). Neither a significant difference in length of intensive care unit stay (MD 0.25, 95% CI - 0.36 to 0.86, P = 0.41) nor a significant difference in hematoma volume expansion was reported (MD - 0.89, 95% CI - 3.11 to 1.34, P = 0.435). Our results suggest that AA is superior to 4F-PCC in enhancing the hemostatic efficacy and reducing the overall and in-hospital mortality rates. More thromboembolic events are thought to be associated with the use of AA. However, more studies are required to validate whether the better results of AA in improving hemostatic efficacy are enough to make up for their higher cost and their possible risk of thromboembolic events.

Implementation and development of hospital-based health technology assessment in Poland from the perspective of hospital representatives: qualitative research.

The analysis of health technologies in Poland has so far mainly concerned drugs assessed by the Agency for Health Technology Assessment and Tariffication, which was established for this purpose. Due to the implementation of various forms of investment (hardware, diagnostic, and organizational) in hospitals, and the growing need to properly assess the costs of implemented solutions, Hospital-Based Health Technology Assessment (HB-HTA) began to develop. In order to implement HB-HTA in the Polish healthcare system, in 2019-2022 a project was carried out, the consortium members of which were: the National Health Fund (NHF), the National Institute of Cardiology in Warsaw (NIKARD), and Lazarski University (UŁ). Analyzing the possibilities of developing HB-HTA in Polish hospitals based on the experiences of the study participants. Presenting benefits and barriers for HB-HTA units implementation to Polish hospitals. Qualitative analysis of in-depth interviews with the representatives of hospitals that participated in the HB-HTA project using the Nvivo12 program. A specially prepared questionnaire with questions regarding the pre-project, design, and post-project phases was presented to respondents from five of the seven hospitals participating in the pilot phase of the project, during which HB-HTA reports were prepared for selected medical technologies. The remaining two facilities that were invited refused to participate in the study. The Ethics Committee of the Jagiellonian University Medical College gave consent to conduct the study. Hospital representatives indicate that the HB-HTA methodology allows for the assessment of investments in facilities based on appropriate data. Thanks to the project, employees of hospital units gained new skills, such as becoming familiar with literature reviews in medical bibliographic databases. However, HB-HTA in Poland has not been fully implemented because facilities do not obtain adequate benefits from the implementation of HB-HTA at the organizational and financial level. According to the study participants, the methodology itself should be modified to take into account the needs of the facility. The hospitals participating in the HB-HTA project are developing the field of analyzing how innovative solutions are implemented in their facilities, but not to the extent that was intended in the project design.

Antifungal susceptibility, molecular epidemiology, and clinical risk factors of Candida glabrata in intensive care unit in a Chinese Tertiary Hospital.

The increasing incidence and high mortality rate of Candida glabrata infection in ICU patients is an important issue. Therefore, it is imperative to investigate the antifungal susceptibility profiles and epidemiological characteristics in local regions. Herein, antifungal susceptibility testing was conducted to determine the minimum inhibitory concentrations (MICs) of eight antifungal drugs. Multilocus sequence typing (MLST) was used to study the strain genotype, geographical distribution, and susceptibility to antifungal agents among C. glabrata isolates. The mechanism of echinocandin resistance was explored by sequencing the FKS1 and FKS2 genes (encoding 1,3-β-D-glucan synthases) of echinocandin-resistant C. glabrata strains. Moreover, we further investigated the clinical manifestations and the various risk factors of patients infected with C. glabrata in the ICU. We selected 234 C. glabrata isolates from 234 patients in the ICU randomly for the follow-up study. Cross-resistance was found among the ICU C. glabrata isolates. Analysis using MLST showed that the genetic diversity among the C. glabrata isolates was low. Furthermore, sequence type showed no correlation with the antifungal resistance profiles, but was associated with geographical distribution. We also revealed novel mutations in FKS1 (S629P) and FKS2 (W1497stop) that mediated high-level echinocandin resistance (MIC >8 µg/mL). More than 14 days' stay in ICU (P=0.007), Acute Physiology and Chronic Health Evaluation II (APACHE-II) score (P=0.024), prior antifungal exposure (P=0.039) and lung disease (P=0.036) were significantly associated with antifungal resistant/non-wild-type C. glabrata infection. Our study shed light on the antifungal susceptibility, molecular epidemiology, and clinical risk factors of C. glabrata in the ICU of a Chinese Tertiary Hospital. Importantly, we revealed the molecular mechanism of echinocandin resistance. These results highlight the significance of continued surveillance in ICUs and provide data support for the treatment of C. glabrata in clinics.

Aggressive Behaviour Risk Assessment Tool for Hospitalised Patients in Non-Psychiatric Inpatient Units.

To refine and validate an electronic version of the Aggressive Behaviour Risk Assessment Tool (ABRAT) and determine the sensitivity and specificity for identifying potentially violent patients in non-psychiatric inpatient units. A prospective cohort study design was used. All patients admitted or transferred to three inpatient units of an acute care hospital in Nebraska, USA, from 7 February to 9 April 2023, were included. The 10-item ABRAT assessments were performed daily for the first 3 days of admission. The violent events were collected until discharge in three categories: Physical aggression towards others, physical aggression towards property and verbal intimidation/threat towards others. Kendall's tau tests and a multivariate logistic regression procedure were performed to select a parsimonious set of items that best predict violent events. Of 1179 patients, 69 had ≥1 violent event (5.9%). The revised six-item tool with item weighting was named ABRAT for Hospitalised Patients (ABRAT-H). The area under the curve from the Receiver Operating Characteristics analysis was 0.82. The sensitivity and specificity at a cutoff score of two were 68.1% and 85.2%, respectively. As ABRAT-H scores increased, the percentage of violent patients also increased and for patients with scores ≥5, 55.2% became violent. ABRAT-H appears to be useful for identifying potentially violent patients in non-psychiatric inpatient units with satisfactory sensitivity and specificity. The availability of ABRAT-H may help provide focused preventive measures that target patients at high risk for violence and reduce violent events. A majority of the nursing workforce is employed in acute care hospital setting, and the availability of ABRAT-H can further enhance the culture of a safe work environment and have positive impacts not only on the nurses' physical and mental health but also on the quality of patient care. We have adhered to relevant STROBE guidelines for reporting observational studies. No Patient or Public Contribution.

Hepatitis B and C viral infections and correlates among pregnant women in Ilorin, Nigeria: a cross-sectional study

Background: Hepatitis B and C are significant viral infections in pregnancy with high risk of maternal and neonatal complications. This study was conducted to determine the prevalence of hepatitis B and C viral infections and correlates among pregnant women who attended antenatal care (ANC) unit of General and Civil Service Hospitals, Ilorin, Nigeria. Methodology: This was a descriptive cross-sectional study of 282 consented pregnant women randomly selected from the ANC units of two hospitals in Ilorin. Blood samples were collected from the pregnant women and tested for hepatitis B virus (HBV) surface antigen (HBsAg) and anti-hepatitis C virus (HCV) antibody using Enzyme Linked Immunosorbent Assay (ELISA) technique. Socio-demographic and obstetrics information of the pregnant women and potential risk factors for HBV and HCV infections were collected using a pretested structured questionnaire. Statistical analysis was done using SPSS version 22.0 Results: Majority of the women were married (78.4%), from monogamous families (57.8%), do not share sharp objects (65.6%), have not received blood transfusion (65.3%), have no history of organ transplantation (91.1%), and multigravida (61.4%,) in their first (36.9%), second (37.2%) and third (25.9%) trimesters of pregnancy. Overall, 22.3% and 1.4% tested positive for HBsAg and anti-HCV respectively. Family background of the study participants showed significant (p˂0.05) association with HBsAg positivity. None of the other analysed variables showed any significant association with both HBsAg and anti-HCV positivity. Conclusion: This result showed high prevalence of HBV but low prevalence of HCV infections among pregnant women in the study setting. Improved surveillance and routine screening for HBV and HCV for women attending ANC is recommended to reduce disease burden and help achieve WHO goal of eliminating viral hepatitis as a major public health threat by 2030.

Assessment and Monitoring of Adverse Drug Reactions at a Tertiary Care Hospital

Background: Incidences of adverse drug reactions were reported through spontane-ous reporting at an ADR monitoring unit in a tertiary care hospital. Aims: This study was conducted to describe the distribution pattern of adverse drug reaction (ADR). Objective: The objective of this study was to monitor and report the adverse drug reactions (ADRs) occurring in a tertiary care hospital and to evaluate the incidence, causality, severity, and preventability of adverse drug reactions. Methods: A prospective, observational study was conducted at a tertiary care hospital in Punjab for 6 months. All patients admitted to the hospital above 18 years of age were included in the study. Results: A total of 103 ADRs were observed over the study period of 6 months. The majority of them were females (60), comprising of 58.25%. The therapeutic class of drug associated with most of the ADRs was antibiotics 18 (17.5%). Maximum number of ADRs occurred in the gen-eral medicine ward with frequency of 27 (26.2%) and were of type b 58 (56.3%). Causality was assessed using the Naranjo scale, and most of the ADRs came out to be probable 64 (62.1%) in nature. Severity was assessed using Hartwig’s severity assessment scale, and most of the cases, 66 (64.1%), were moderate in intensity. ADR preventability was assessed using the Schumock and Thornton preventability scale, and it was observed that most of the cases, 82 (79.6%), were not preventable. Conclusion: This study seeks to strengthen the ADR database through analysis of spontaneous reporting patterns of ADRs from various clinical departments of a tertiary care teaching hospital, thereby increasing awareness and improving the reporting culture among health care practition-ers. It can be concluded that continuous medication monitoring and a well-organized and com-mitted pharmacovigilance system led by a clinical pharmacist in a hospital setting would un-doubtedly lower the incidence of adverse drug reactions.

The frequency, risk factors, onset time, and outcome of acute kidney injury induced by vancomycin, colistin, and liposomal amphotericin B in hospitalized patients

Introduction: Medications are among the major causes of acute kidney injury (AKI) in hospitalized patients. Objectives: This study aimed to explore the frequency, characteristics, risk factors, and clinical outcomes of AKI induced by vancomycin, colistin, and liposomal amphotericin B (L-AmB) in hospitalized patients across various wards of two educational hospitals in Shiraz, Iran. Patients and Methods: From October 2022 to May 2023, an observational cross-sectional study was conducted in both intensive care unit (ICU) and non-ICU wards of Namazi and Shahid Faghihi hospitals, Shiraz, Iran. Patients aged 18 and older, without a documented history of AKI or chronic kidney disease, scheduled to receive treatment with vancomycin, colistin, or L-AmB for at least one week, were considered eligible. Relevant data, including demographic, clinical, and laboratory findings, were collected. Results: AKI was observed in 36 (34.3%) out of 105 patients during treatment. The incidence rates of AKI were 29%, 55%, and 31.1% in vancomycin, colistin, and L-AmB recipients, respectively. The mean ± SD time to AKI onset was 5.44 ± 2.04 days (range; 3 to 13 days). Dehydration at admission significantly increased the risk of antibiotic-induced AKI (odds ratio [OR] = 3.686, 95% confidence interval [CI] = 1.226–11.081, P = 0.020). Co-administration of aminoglycosides (OR = 8.422, 95% CI = 1.846 – 38.426, P = 0.006), diuretics (OR = 3.763, 95% CI = 1.092–12.965, P = 0.036), and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (OR = 7.149, 95% CI = 1.534–33.308, P = 0.012) were also identified as independent risk factors. The in-hospital mortality rate was significantly higher in patients with AKI than in those without AKI (8.6% vs. 6.7%; P < 0.044). Conclusion: AKI induced by vancomycin, colistin, and L-AmB occurred in about one-third of our study population, primarily within five days of initiating treatment. Dehydration and co-administration of nephrotoxic medications were significantly associated with AKI. Clinicians should explicitly address these factors in preventive strategies to reduce antibiotic-induced AKI in hospitalized patients.

Nosocomial carbapenem-drug resistant Acinetobacter baumannii, related factors and clinical outcomes in Northeast Iran

Background and objectivesNosocomial infections, including drug-resistant Acinetobacter baumannii infections, continue to impact the health of hospitalized patients. This study sought to determine the prevalence of these infections and assess the associated risk factors and clinical outcomes in Gorgan, Iran.MethodsA retrospective cross-sectional study was conducted on 143 infected patients with Acinetobacter baumannii in two educational hospitals in Gorgan city, Iran between 2016 and 2018. Patient information including age, gender, reason and duration of hospitalization, background of diseases, type of sample culture, symptoms, laboratory findings, prescribed antibiotics, and antibiogram were collected and analyzed. The Logistic regression and survival statistical methods were used by software of SPSS 26.ResultsA total of 37 patients (25.87%) died during hospitalization. The less than one year and 45–65 years age groups demonstrated more deaths (29.7%; p-value < 0.001). Being single (not being married) was found to be a risk factor in increasing the chance of death among patients (OR = 2.154, 95% CI: 1.02–4.53; p = 0.048). Hospitalization in intensive care units (ICUs) was a risk factor for the death of patients (OR = 4.655, 95% CI: 7.6–83.2). The resistance to carbapenems was reported to be an important risk factor for the death of patients.ConclusionsAcinetobacter baumannii infections, particularly those resistant to carbapenems, are a significant risk for patients in ICUs and can lead to higher mortality rates.

The relationship between positive end-expiratory pressure (PEEP) and intra-abdominal pressure (IAP) in mechanically ventilated patients: A prospective observational study.

Positive end-expiratory pressure is a crucial mechanical breathing parameter. Intra-abdominal hypertension is well defined as a sustained increase in the intra-abdominal pressure ≥12 mmHg. There are still controversies about mechanical ventilation's effect and use of positive end-expiratory pressure on intra-abdominal pressure. We aimed to delineate the relationship between positive end-expiratory pressure and intra-abdominal pressure in mechanically ventilated patients admitted to the intensive care units of a large tertiary hospital in Upper Egypt. This study was a prospective observational study. The study was conducted at a university hospital from October 2023 to February 2024. The enrolled adult patients were allocated into two groups based on their positive end-expiratory pressure: group I, low pressure (<8 cm H2O) and group II, high pressure (8-10 cm H2O). A total of 120 patients were enrolled, 60 patients in each group. The most commonly encountered diagnoses were pneumonia (32/120, 26.7%) and acute respiratory distress syndrome (ARDS) (31/120, 25.8%), respectively. There was a significant difference between the intra-abdominal pressure mean values of the two patient groups, 18.9 ± 3.3 versus 24.4 ± 5.9 mmHg in the group of low versus high pressure (correlation value of .454, p < .001), respectively. There were highly significant correlations between intra-abdominal pressure categories and the patient groups (correlation value of .495, p < .001). There were 24 (40%) versus 0 (0%) patients of high pressure versus low pressure within the category IV group of intra-abdominal hypertension (>25 mmHg). We observed a significant relationship between positive end-expiratory pressure and intra-abdominal pressure in mechanically ventilated patients. The patient group with high pressure had higher mean values compared with the group with low pressure. The study highlights the importance of closely monitoring intra-abdominal pressure in mechanically ventilated patients who receive positive end-expiratory pressure. Further studies are warranted. The relationship between positive end-expiratory pressure and intra-abdominal pressure is an essential issue in daily critical care nursing clinical practice. Considering the occurrence of multiple organ dysfunction as a result of a non-detected increase in intra-abdominal pressure, critical care nurses should pay attention to measuring this pressure to maintain intra-abdominal pressures that are safe for mechanically ventilated and critically ill intensive care unit patients, thereby preventing these undue effects.

Profile of antimicrobial use and potential use of the defined daily dose in neonatology

One of the measures for monitoring microbial resistance is the calculation of the defined daily dose of antimicrobial agents. For this calculation, the weight of an adult of 70 kg is used as a standard, so that application in neonatology is not possible. The aim of this study is to describe the use profile and calculate the defined daily dose (DDD) of antimicrobials in a neonatal intensive care unit (NICU) of a public hospital in the interior of Bahia, Brazil. From March 2020 to December 2021, the medical records of 712 newborns admitted to a NICU between September 2018 and June 2020 were analyzed. A total of 410 newborns diagnosed with neonatal sepsis were included. The most used antimicrobials per patient were gentamicin (408/410; 99.5%), ampicillin (407; 99.3%), amikacin (29; 7.1%) and oxacillin (21; 5.1%), with a mean (SD) treatment duration of 9.8 (3.9) days. The most commonly used combination of antimicrobials was ampicillin with gentamicin, which was used in 406 patients (99.0%). The values for neonatal DDDs were on average 26 times lower than those for adult DDDs. The neonatal DDDs were similar to those observed in other studies. Ampicilin and cefepime were the antimicrobials for which the greatest differences were observed in neonatal DDDs compared with adult DDDs, which differed mainly between maintenance doses, reflecting the lack of international standards in neonatology. Standardization of DDDs as a surveillance measure has the potential to clarify the pattern of antimicrobial use in neonatal patients worldwide and, in particular, to prevent indiscriminate use and bacterial resistance.

The influence of job enrichment on job embeddedness and sick presenteeism among nurses.

To understand how job enrichment influences job embeddedness and sick presenteeism among nurses. Job satisfaction and retention are critical issues in healthcare, particularly among nurses. Job enrichment has been identified as a potential strategy to enhance job satisfaction and reduce turnover rates. Understanding its impact on job embeddedness and sick presenteeism can inform policies to improve nurse well-being and organizational effectiveness. A cross-sectional descriptive design following STROBE guidelines was used. Data were collected from 360 nurses working in critical care units of a large university hospital. Three scales were used to measure job enrichment, job embeddedness, and sick presenteeism. Nurses reported high job enrichment and embeddedness levels. However, a significant proportion also exhibited high levels of sick presenteeism. Strong positive correlations existed between job enrichment, job embeddedness, and sick presenteeism. Regression analyses revealed that job enrichment significantly predicted job embeddedness and sick presenteeism. The findings highlight the complex interplay between job characteristics, organizational commitment, and employee health behaviors among nurses. Job enrichment emerged as a critical factor influencing job satisfaction, organizational commitment, and sick presenteeism. The study underscores the need for health policies that promote job enrichment strategies, as they can contribute to nurse retention, reduce sick presenteeism, and enhance productivity in healthcare settings. Nurse retention and job satisfaction can be improved by implementing job enrichment practices in healthcare organizations. Policies to reduce sick presenteeism should prioritize creating healthier work environments and promoting employee well-being. Understanding the cost-effectiveness and productivity gains associated with job enrichment can inform workforce planning and staffing policies, ensuring adequate nurse staffing levels and quality patient care.

Postoperative Complications in Lingual Versus Palatine Tonsillectomies.

The aim of this study was to investigate the risks of lingual tonsillectomy (LT) in a large cohort and compare these risks to those of palatine tonsillectomy (PT). A retrospective cohort study was conducted using data from the United States collaborative network within TriNetX. The LT group was defined using Current Procedural Terminology (CPT) code 42870 and PT group using CPT codes 42820, 42821, 42825, or 42826. Groups were further subdivided into pediatric and adult populations and matched based on propensity scores within the cohorts. Complications occurring within 14 days of procedure were compared within each cohort. There were 1,357 adult patients (mean age, 42.9 years) and 863 pediatric patients (mean age, 8.1 years). Adults who had LT were more likely to experience postoperative dysphagia (OR = 2.6, p < 0.001) and require admission to the hospital (OR = 4.3, p < 0.001) or intensive care unit (OR = 6.1, p < 0.001). There was no significant difference in bleeding between adult PT and LT groups, occurring at rates of 3.8% and 4.4%, respectively (p = 0.50). Pediatric patients who had LT were also more likely to experience postoperative dysphagia (OR = 2.4, p = 0.017) and require admission to the hospital (OR = 8.2, p < 0.001) or intensive care unit (OR = 2.7, p = 0.012). The postoperative bleed rate was 3.2% in the pediatric PT cohort, which was 2.4 times higher compared to those who underwent LT (1.5%, p = 0.016). Postoperative complications after lingual tonsillectomy are more common than after palatine tonsillectomy in both adults and children. III Laryngoscope, 2024.

Role of Xpert PCR kit in assessing MRSA colonization in medical and surgical units of a tertiary care teaching hospital

Background and rationaleMethicillin resistant Staphylococcus aureus (MRSA) colonization increases the risk of MRSA infection. Detecting MRSA colonization can influence postoperative outcomes and prolong hospital stay. The conventional standard culture method for detecting MRSA colonization has limitations in terms of sensitivity and turnaround time. Hence, we sought out use of Xpert PCR kit for prompt evaluation of MRSA colonization to support MRSA prevention in a tertiary care hospital in Karachi, Pakistan.Materials and methodsDuring 1st April-31st December 2022, 290 nasal and skin swab samples were collected from 257 patients and processed using routine culture (as gold standard method) and PCR-based MRSA detection assay (MRSA Xpert).ResultsA total of two hundred and ninety (290) swab samples from 257 patients were obtained, 33 of which were paired. The overall prevalence of MRSA colonization was 12% by both methods, with 90% of cases classified as community-associated (CA-MRSA) whereas 10% as hospital-acquired (HA-MRSA). The colonized group showed a higher subsequent MRSA infection rate (11% vs. 3.5%) compared to the noncolonized group. Culture identified 11% of screening samples as MRSA positive, Xpert MRSA assay showed 100% sensitivity and 95% specificity. The cost of a single MRSA Xpert assay was $50 while MRSA culture cost around $7.50.ConclusionOur study findings suggest that the presence of MRSA colonization in our cohort of patients is consistent with the existing trends in hospital epidemiology. Both conventional culture and Xpert MRSA methods showed comparable efficacy for detection of MRSA colonization. Larger-scale studies are recommended to validate these findings conclusively.

Short-term results of a multicenter study based on a modified N7 induction regimen combined with arsenic trioxide in the treatment of children with high-risk neuroblastoma

Objective: To analyze the short-term clinical efficacy and safety of arsenic trioxide (ATO) combined with a modified N7 induction regimen in the treatment of children with high-risk neuroblastoma (NB). Methods: This study was a prospective, single-arm, multicenter phase Ⅱ clinical study. Sixty-seven high-risk NB children from eight units of Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Wuhan Children's Hospital of Tongji Medical College of Huazhong University of Science and Technology, First Affiliated Hospital of Guangxi Medical University, Hainan General Hospital, Affiliated Hospital of Guangdong Medical University, Kunming Children's Hospital, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, and Guangdong Provincial Agricultural Reclamation Center Hospital were enrolled from January 2019 to August 2023 and were treated with ATO combined with a modified N7 induction regimen. The efficacy and adverse effects at the end of induction chemotherapy were assessed and analyzed, and the differences in the clinical characteristics were further compared between the treatment-responsive and treatment-unresponsive groups by using the Fisher's exact test. Results: Among 67 high-risk NB children, there were 40 males (60%) and 27 females (40%), with the age of disease onset of 3.5 (2.6, 4.8) years. Primary NB sites were mostly in retroperitoneum (including adrenal gland) (56/67, 84%) and the common metastases sites at initial diagnosis were distant lymph node in 25 cases (37%),bone in 48 cases (72%),bone marrow in 56 cases (84%) and intracalvarium in 3 cases (4%). MYCN gene amplification were detected in 28 cases (42%). At the end of induction, 33 cases (49%) achieved complete remission, 29 cases (43%) achieved partial remission, 1 case (1%) with stable disease, and 4 cases (6%) were assessed as progressive disease (PD). The objective remission rate was 93% (62/67) and the disease control rate was 94% (63/67). The percentage of central system metastases at the initial diagnosis was higher in the treatment-unresponsive group than in the treatment-responsive group (2/5 vs. 2% (1/62), P=0.013), whereas the difference in MYCN gene amplification was not statistically significant between two groups (3/5 vs.40% (25/62), P=0.786). Grade Ⅲ or higher adverse reactions during the induction chemotherapy period were myelosuppression occurred in 60 cases (90%), gastrointestinal symptoms occurred in 33 cases (49%), infections occurred in 20 cases (30%), hepatotoxicity occurred in 4 cases (6%), and cardiovascular toxicity occurred in 1 case (2%). There were no chemotherapy-related deaths. Conclusion: ATO combined with N7-modified induction regimen had a superiority in efficacy and safety, which deserved further promotion in clinical practice.

The effectiveness of early mobilisation on physical function in patients after heart valve surgery: a systematic review

Background/Aims Literature suggests that early mobilisation, defined as the initiation of physical activity within 48 hours following surgery, improves outcomes after cardiac surgery. This systematic review assessed the effectiveness of early mobilisation on physical function and other outcomes, including length of hospital stay and cost following heart valve surgery. Methods The Physiotherapy Evidence Database, MEDLINE, EMBASE, CINAHL and Cochrane Library were systematically searched from inception until May 2022 using relevant key words. Randomised controlled trials comparing early mobilisation and usual care for patients who had received heart valve surgery were included in the review. Methodological quality was assessed using the Physiotherapy Evidence Database scale and risk of bias using the Cochrane Risk of Bias 2 tool. The data were narratively synthesised. Results The search identified 210 articles, with 98 remaining after duplicates were removed. Upon screening for eligibility, nine articles were assessed in full and three randomised controlled trials involving 161 patients were included in the review. Early mobilisation protocols varied across trials. Two trials (n=124) reported significantly greater improvement in physical function with early mobilisation compared to usual care, including handgrip strength (P=0.001). One study (n=41) found early mobilisation significantly reduced the length of hospital stay (P=0.000), in-hospital care costs (P=0.000) and intensive care unit stay (P=0.000) compared to usual care. Methodological quality scores ranged from six to nine on the Physiotherapy Evidence Database scale. The risk of biased judgement was ‘low’ in one study and ‘some concerns’ in two studies. Conclusions Early mobilisation may improve physical function and reduce hospital and intensive care unit stays after heart valve surgery. However, differences in protocols and limited studies indicate further high-quality research is needed, particularly regarding cost-effectiveness. Establishing clear early mobilisation protocols could enhance recovery in this population. Implications for practice Early mobilisation may require the coordinated effort of a multidisciplinary team of physiotherapists, nurses and possibly other medical professionals. For its seamless and effective implementation, it is essential to understand whether this intervention falls under the domain of physiotherapists or requires broader team collaboration. Given these complexities, strategies targeting early mobilisation that balance both safety and resource considerations are advised to improve physical function after heart valve surgery, especially among patients who are frail.

B-199 Rapid Molecular Detection of Meningitis Agents in Diverse Brazilian Regions (2019-2023): A Multicenter Study

Abstract Background Meningitis, caused by viral and bacterial agents, is a significant public health issue globally, with a substantial economic impact. In Brazil, the incidence of meningitis varies by region, making the identification of the causative agent crucial for effective treatment. This study aims to evaluate the epidemiology of meningitis agents diagnosed using a rapid molecular detection panel in samples from various hospital units of a nationwide diagnostic and healthcare company. Methods Samples from several hospitals across different regions of Brazil were analyzed using the FilmArray® rapid molecular panel for meningitis and encephalitis, capable of identifying up to 14 agents, including bacteria, viruses, and fungi/yeasts. Gender, age group, regional distribution, and agent prevalence from January 2019 to April 2023, were retrieved from the database ensuring compliance with the Brazilian Data Privacy and Protection (LGPD) and local Research Ethics Committee guidelines. Results The study included 485 patients from 41 cities across 11 Brazilian states. The age range was 0 to 96 years, with an average age of 45 years, and a majority of female participants (59%). The highest number of test requests occurred in 2022 (17.5%), followed by 2021 (10%), with 2019, 2020, and 2023 accounting for less than 5% of requests each. The overall positivity rate was 10.5% (51/485), with 92.8% (13/14) of the possible agents identified. Viral agents were detected in 60.7% of positive cases, bacterial agents in 39.2%, and one mixed infection (human herpesvirus 6 and Escherichia coli K1) in a 2-year-old child. No fungal/yeast infections were detected. The most common agents were varicella-zoster virus (18.2%), Haemophilus influenzae (12.7%), herpes simplex viruses type 1 and 2 (12.7% each), and enterovirus (12.7%). Conclusions The study highlights the importance of rapid molecular diagnostic methods in Brazilian clinical-laboratory practice, offering fast, safe, and sensitive detection of meningitis-causing agents, which can contribute to improved patient outcomes.

B-198 Rapid Molecular Detection of Respiratory Infections in Brazilian Hospitals and Outpatient Units: Insights from the Diagnostic Medicine and Health Network

Abstract Background Diagnosing agents causing respiratory infections remains a global challenge due to the numerous coexisting agents and similar symptoms. This study evaluates the epidemiology of viral and bacterial agents responsible for major respiratory infections through molecular detection in patients across various Brazilian hospital units served by a clinical diagnostic and health laboratory. Understanding the distribution and prevalence of these pathogens is crucial for effective diagnosis, treatment, and prevention strategies in the face of evolving epidemiological landscapes. Methods Utilizing an internal database, we conducted a comprehensive analysis of tests performed on the FilmArray® system. This system employs multiplex PCR technology, capable of simultaneously identifying 21 respiratory agents in a single sample obtained from nasopharyngeal and bronchial lavage specimens collected from diverse geographical regions across Brazil. The data for the examination of patient samples with respect to gender, age group, geographical regions, and the prevalence of various agents between January 2021 and April 2023 were retrieved from the database and analyzed. To ensure privacy, sensitive and individual data from all patients were meticulously preserved throughout the study. Results The analysis encompassed a diverse sample of 477 patients, originating from 26 cities across 11 Brazilian states, including Goiás, Minas Gerais, Mato Grosso, Pará, Paraná, Rio de Janeiro, São Paulo, Tocantins, Amazonas, Bahia, and Distrito Federal. The distribution of patients was nearly split between hospital settings (39.8%) and outpatient units, with hospital patients predominantly from departments such as internal medicine, cardiology, and nephrology. In contrast, outpatient samples were primarily requested by specialists in pulmonology and infectious diseases. The demographic profile revealed an average age of 36 years, with a majority male representation (54%). However, a notable shift occurred in the first four months of 2023, where females constituted 60.8% of the sample. The overall test positivity rate stood at 42.3%, with a significant detection of 71% (15 out of 21) of the surveyed respiratory agents at some point during the study period. The most frequently identified pathogens were Rhinovirus, Enterovirus, and SARS-CoV-2, collectively accounting for 55.1% of the positive findings. Additionally, mixed infections were observed in 29 (6%) of the patients, with combinations such as SARS-CoV-2 and Rhinovirus, SARS-CoV-2 and H3N2, and SARS-CoV-2 and RSV, among others, highlighting the complexity of respiratory infections. Conclusions The findings from this study underscore the critical role of advanced molecular diagnostics in the Brazilian clinical-laboratory landscape. The utilization of multiplex PCR technology has proven to be a pivotal tool in accurately identifying a wide array of respiratory pathogens, thereby enhancing the precision of diagnosis and treatment strategies. The detection of a high prevalence of agents such as Rhinovirus, Enterovirus, and SARS-CoV-2, along with the identification of mixed infections, highlights the complexity of respiratory infections and the necessity for robust diagnostic tools. This study not only contributes to the understanding of the epidemiology of respiratory infections in Brazil but also emphasizes the importance of continuous advancements in molecular diagnostics for better patient care and public health management.

Serratia marcescens outbreak at a neonatal intensive care unit in an acute care tertiary hospital in Singapore

To report the epidemiological, diagnostic, and genetic investigation of an outbreak of neonatal patients infected or colonized with Serratia marcescens (S. marcescens) including the infection control interventions. Outbreak investigation report. 28-bedded neonatal unit in an acute care tertiary hospital in Singapore divided into three areas: two negative-pressure airborne infection isolation rooms with a shared anteroom, 10 neonatal intensive care unit (NICU) beds, and 16 high dependency beds. A total of five neonates were involved in this outbreak. Screening of in-flight patients and their immediate environment for S. marcescens to determine probable environmental sources, whole genome sequencing (WGS) analysis of resulting isolates to determine clone-relatedness and possible transmission patterns. Implementation of infection control interventions included prompt isolation of cases, enhanced equipment and environmental disinfection, use of alcohol-based hand rub as the preferred hand hygiene mode, enhanced infection prevention orientation for parents, review of practices, audits, and immediate feedback on non-compliance. Five neonates infected or colonized with S. marcescens were involved in this outbreak. Four were infection cases whilst one identified through contact tracing. Three NICU sinks and the milk preparation room sink were tested positive for S. marcescens. WGS confirmed clonality of strains from two NICU sinks, and milk preparation room sink with that of the five neonates. Multiprong strategy was required to contain this outbreak. WGS analysis showed association of biofilms in sinks with the outbreak.

Molecular diversity in fusidic acid-resistant Methicillin Susceptible Staphylococcus aureus.

The recent emergence of fusidic acid (FA)-resistant Staphylococcus aureus has underscored the importance of active surveillance in isolating these strains. The molecular basis of fusidic acid resistance and the carriage of virulence factors in four borderline oxacillin-resistant Staphylococcus aureus (BORSA) clinical strains was assessed through phenotypical and genotypical methods. All S. aureus clinical strains were obtained from various hospital units in Sicily. In vitro antibiotic susceptibility testing was conducted. WGS was performed using the Illumina MiSeq Platform, and data analysis was carried out to determine ST, resistome and virulome profiles. Genotypic characterization revealed that the strains belong to four STs: ST630, ST8, ST15, and ST1. FA resistance was associated with mutations in the fusA gene or fusB and fusC genes. Additionally, one case exhibited resistance to mupirocin, related to the presence of the mupA gene. Borderline MIC values were observed for cefoxitin in three out of four cases, leading to their categorization as BORSA. Virulence gene content was complex and diversified, with one testing positive for the lukS/F genes, coding for PVL toxin. Resistance to FA is multifactorial, involving point mutations in chromosomal genes or association with mobile genetic elements. Monitoring the resistance to these antibiotics might help to manage and eradicate mupirocin- and FA-resistant S. aureus strains, which are also known to be important carriers of virulence determinants.