In-hospital Infection Research Articles

Is There a Weather Seasonal Effect on Acute Pancreatitis Etiology and Outcomes?

Introduction: Approximately 20% of Acute pancreatitis (AP) cases are deemed to be idiopathic. Gallstone disease has been reported to have increased incidence during summer and this could be due to variations in temperature during these months. The aim of this study was to identify the prevalence of different AP etiologies during the weather seasons and to investigate the association between temperature variation, seasonal effect and the onset of acute pancreatitis, its severity and outcomes. Methods: We performed a retrospective cohort study of consecutive patients admitted with a very first episode of acute pancreatitis at a large public hospital in Chicago between 01/2013 and 12/2014. We identified acute pancreatitis diagnosis by ICD9 code and/or lipase ≥ 3 times the normal upper limit. Two physicians reviewed each case to include only first episodes of acute pancreatitis. We excluded patients who were transferred to our center. We included a detailed weather season history and temperature in Celsius degree on the day of admission for each AP case from the publically available website: weather. com. We constructed multivariable logistic regression models. Results: We analyzed 460 patients. Mean age was 48 years (range 17 to 89 years), 54% were males. In Univariate and Multivariate analysis, having an AP episode during winter was found to be protective against Acute Kidney Injury (AKI) (aOR: 0.4, P<0.005, CI 0.2-0.9). After adjusting for admission SIRS, age and gender; Weather seasons were found to impact AP etiology nor be independent risk factors for Persistent Systemic Inflammatory Response Syndrome (SIRS), AKI, ARDS, pancreatic necrosis, mortality, ICU, Length of Stay (LOS), in-hospital infections, BISAP score, nor recurrent AP. In addition, the mean temperature (T) of Chicago (15°C) was compare to lower temperatures as well as higher temperature variations; Higher temperatures than the average Chicago T was found to be protective against Persistent SIRS at 48h (aOR 0.6, P<0.05, CI 0.3-0.9). No other significant impact on these temperatures variations was found. Conclusion: Weather Seasonal effect was not found to impact the etiology of acute pancreatitis. All etiologies were equally distributed among all seasons. However, AKI during winter was found to have a significantly lower incidence and Persistent SIRS had lower incidence during higher or warmer temperatures. This is the largest study to date to examining weather seasonal effect in AP.

Hospital-Acquired Infection Is the Strongest Predictor of In-hospital Mortality in Patients With Alcoholic Hepatitis

Introduction: Alcoholic hepatitis (AH) is a clinical syndrome associated with high mortality and utilization of resources. We performed this study to evaluate predictors of in-hospital mortality (IHM) among AH patients. Methods: A retrospective chart review was done on patients discharged from our hospital with a diagnosis of AH. Patients who met a well characterized definition of AH (serum bilirubin > 3 mg/dL, AST to ALT ratio of > 1.5, recent heavy alcohol use, and absence of other causes of liver disease) were included in the study. Chi-square and t-tests were used to compare categorical and continuous variables. Multivariate logistic regression was used to evaluate the impact of several variables on IHM. Results: 105 patients with AH (median age 46yrs, 56% male, 74% white, 57% with cirrhosis, MELD score 23) were included in the study. Complications present on admission included acute kidney injury (AKI) (44%), encephalopathy (29%), infection (24%), and gastrointestinal bleeding (17%). Complications that developed during the hospitalization included AKI (48%) with 8% requiring dialysis, infection (15%), encephalopathy (12%), and gastrointestinal bleeding (5%). 67 patients (64%) received treatment for AH including steroids (n=33), pentoxifylline (21), or both (n=13).15 patients (14%) died during hospitalization. Compared to those that survived hospitalization, patients with IHM had a higher incidence of AKI on admission (73 vs. 39%, P=0.013), in-hospital AKI (73 vs. 20%, P < 0.0001), in-hospital encephalopathy(40 vs. 8%, P=0.0005), in-hospital infection (47 vs. 10% P=0.0003), pentoxifylline use (60 vs. 28%, P=0.014), and in-hospital renal replacement therapy (33 vs. 3%, P < 0.0001). They were also more likely to meet SIRS criteria (73 vs. 46%, P=0.046) and have a higher admission MELD score (32 vs. 23, P=0.0003). The use of prophylactic antibiotics was similar among patients with IHM and those who survived hospitalization (33 vs. 29%, P=0.73). On multivariate logistic regression, hospital-acquired infection was the single most important predictor for IHM (OR 15, 2.3-99, P=0.005). Prophylactic antibiotic use (OR 1.04, 0.14-8.1, P=0.96) and admission MELD score (OR 1.07, 0.98-1.17, P=0.13) were not predictive of IHM. Conclusion: Patients with AH have high in-hospital mortality and hospital acquired infection appears to be the strongest predictor of IHM. Prophylactic antibiotic use does not affect IHM and so clinicians should be vigilant to reduce the risk of infection and treat appropriately if there is evidence of an infection.

Dynamics of 90-Day Mortality After In-hospital Clostridium difficile Infection and C.difficilenegative Controls

Introduction: Clostridium difficile infection (CDI) has surpassed MRSA as the most common nosocomial infection although it only amounts to a subset of antibiotic associated diarrhea (AAD). Close to one in five inpatients with CDI die within 30 days of diagnosis. High mortality rates have been reported for hospital patients with CDI. However, death rates in inpatients with AAD who test negative for C.difficile have received less attention. We aim to determine the 90-day mortality for inpatients with CDI and AAD patients testing negative for C. difficile; describe the temporal distribution of mortality for these patient populations and whether advancing age affects their mortality in a similar manner. Methods: Inpatients positive and negative for toxinogenic C. difficile NAAT were prospectively identified at a large academic medical center in 2015-2016 via Electronic Health Records (EHR). Mortality was ascertained by EHR review (documentation of expiration, absence of kept follow-up appointments and admissions) combined with Google search for obituaries with matching name, date of birth and town of residence. Chi-squared, Fisher exact tests, Kaplan-Maier estimates and Cox regression were used as appropriate. Results: A total of 298 inpatients with AAD were identified, 155 had CDI and 143 did not. Age and female gender did not differ significantly (P=0.563|P=0.342) between CDI (64.1±15.7|47.4%) and non-CDI AAD groups (64.6±17.3|49.4%). Ninety-day all-cause mortality after the onset of AAD did not differ significantly between CDI and non-CDI groups (21.3% vs. 22.4%, P=0.82). The temporal distribution of death differed among CDI and non-CDI AAD groups (P=0.013, see Fig. 1). Age of 65 or above was associated with increased risk of death in the CDI group (HR 4.01 [95%CI 1.81-8.89], P<0.001, see Fig. 2) but this association was at best borderline significant in the non-CDI group (HR 2.16 [95%CI 0.97-4.83], P=0.061, see Fig. 3). The event rate in the non-CDI group yields a power of 97.5% to detect an association between age and mortality of similar effect-size as the one found in the CDI group.Figure: Temporal distribution of mortality for CDI and non-CDI patients.Figure: Survival estimates for CDI inpatients by age 65 or above or below 65.Figure: Survival estimates for non-CDI inpatients by age 65 or above or below 65.Conclusion: Inpatients with AAD have a similar 90-day mortality of about one in five patients regardless of C. difficile status. Most deaths in inpatients with CDI occur in the first month after diarrhea onset and then decrease in the next 2 months which differs from inpatients with non-CDI AAD who have a U-shaped temporal dynamic. The association between age of 65 or older and mortality is more pronounced in CDI compared to non-CDI AAD. Further studies about the causes of death of inpatients with AAD may clarify these temporal dynamics of death and its relationship with advancing age. Reports of death rates in patients with CDI need to be interpreted in light of our findings.

НЕБЕЗПЕЧНА ДИНАМІКА ІНФЕКЦІЙНОЇ ЗАХВОРЮВАНОСТІ В УКРАЇНІ

Мета роботи – проаналізувати інфекційну захворюваність в Україні за останні роки і обґрунтувати причини епідеміологічних ускладнень.Вказано на основні загрози активізації інфекційних хвороб в Україні та причини несприятливої епідеміологічної ситуації, що склалася на сьогодні. Наведено динаміку захворюваності та смертності від цих хвороб за період з 2010 по 2011 рр. Перелічені хвороби, які супроводжувалися у 2016 р. приростом захворюваності в абсолютних числах і з розрахунку на 100 тис. населення. Зроблено акцент на почастішання епідемічних спалахів. Обґрунтована важливість проблеми внутрішньолікарняних інфекцій і необхідність їх повнішої реєстрації. Показана доцільність внесення змін у список орфанних інфекцій, затверджений МОЗ України.Висновок. В Україні зростає інфекційна захворюваність на ряд нозологічних форм і почастішали епідемічні ускладнення, що потребує більших профілактичних, протиепідемічних і клінічних зусиль. Першочергові заходи слід спрямувати на усунення (послаблення) названих причин такого стану.Ключові слова: інфекційна захворюваність, смертність, приріст захворюваності, епідемічні спалахи, внутрішньолікарняні інфекції, орфанні інфекції.

Men Experience Higher Risk of Pneumonia and Death After Intracerebral Hemorrhage.

Infectious complications worsen outcome after intracerebral hemorrhage (ICH). We investigated the impact of sex on post-ICH infections and mortality. Consecutive ICH patients (admitted to a single hospital between 1994 and 2015) were retrospectively assessed via chart review to ascertain the following in-hospital infections: urinary tract infection (UTI), pneumonia, and sepsis. Adjusted logistic regression was performed to identify associations between sex, infection, and mortality at 90days. Two thousand and four patients were investigated, 1071 (53.7%) males. Men were more likely to develop pneumonia (21.9 vs 15.5% p<0.001) and sepsis (3.4 vs 1.6%, p=0.009), whereas women had higher risk of UTI (19.9 vs 11.7% p<0.001). Multivariate analyses confirmed association between male sex and pneumonia (Odds Ratio (OR) 1.37, 95% confidence interval (CI) 1.08-1.74, p=0.011). Male sex (OR 1.40; CI 1.07-1.85; p=0.015) and infection (OR 1.56; CI 1.11-1.85; p=0.011) were independently associated with higher 90-day mortality. Types and rates of infection following ICH differ by sex. Male sex independently increases pneumonia risk, which subsequently increases 90-day mortality. Sex-specific preventive strategies to reduce the risk of these complications may be one strategy to improve ICH outcomes.

Discharge or admit? Emergency department management of incidental pulmonary embolism in patients with cancer: a retrospective study

BackgroundHospitalization and early anticoagulation therapy remain standard care for patients who present to the emergency department (ED) with pulmonary embolism (PE). For PEs discovered incidentally, however, optimal therapeutic strategies are less clear—and all the more so when the patient has cancer, which is associated with a hypercoagulable state that exacerbates the threat of PE.MethodsWe conducted a retrospective review of a historical cohort of patients with cancer and incidental PE who were referred for assessment to the ED in an institution whose standard of care is outpatient treatment of selected patients and use of low-molecular-weight heparin for anticoagulation. Eligible patients had received a diagnosis of incidental PE upon routine contrast enhanced chest CT for cancer staging. Survival data was collected at 30 days and 90 days from the date of ED presentation and at the end of the study.ResultsWe identified 193 patients, 135 (70%) of whom were discharged and 58 (30%) of whom were admitted to the hospital. The 30-day survival rate was 92% overall, 99% for the discharged patients and 76% for admitted patients. Almost all (189 patients, 98%) commenced anticoagulation therapy in the ED; 170 (90%) of these received low-molecular-weight heparin. Patients with saddle pulmonary artery incidental PEs were more likely to die within 30 days (43%) than were those with main or lobar (11%), segmental (6%), or subsegmental (5%) incidental PEs. In multivariate analysis, Charlson comorbidity index (age unadjusted), hypoxemia, and incidental PE location (P = 0.004, relative risk 33.5 (95% CI 3.1–357.4, comparing saddle versus subsegmental PE) were significantly associated with 30-day survival. Age, comorbidity, race, cancer stage, tachycardia, hypoxemia, and incidental PE location were significantly associated with hospital admission.ConclusionsSelected cancer patients presenting to the ED with incidental PE can be treated with low-molecular-weight heparin anticoagulation and safely discharged. Avoidance of unnecessary hospitalization may decrease in-hospital infections and death, reduce healthcare costs, and improve patient quality of life. Because the natural history and optimal management of this condition is not well described, information supporting the creation of straightforward evidence-based practice guidelines for ED teams treating this specialized patient population is needed.

Prospective Study of Postoperative Glycemic Control with a Standardized Insulin Infusion Protocol after Infrainguinal Bypass and Open Abdominal Aortic Aneurysm Repair

The aim of this study is to examine the effect of moderate postoperative glycemic control in diabetic and nondiabetic patients undergoing infrainguinal bypass (INFRA) or open abdominal aortic aneurysm (OAAA) repair. In a single center prospective study, we investigated postoperative glycemic control using a standardized insulin infusion protocol after elective INFRA bypass (n=53, 62%) and OAAA repair (n=33, 38%) between January 2013 and March 2015. The primary end point was optimal glycemic control, defined as having ≥85% of blood glucose values within the 80-150mg/dL target range. Suboptimal glycemic control was defined as <85% of blood glucose values within the blood glucose target range. Secondary end points included in-hospital and 30-day surgical site infection (SSI) rates, composite adverse events, length of stay (LOS), and hospital cost. Optimal glycemic control was achieved more commonly after OAAA repair than INFRA bypass (85% vs. 64%, P=0.04). Moderate hypoglycemia (<70mg/dL) was observed in 32 (37%) patients, while severe hypoglycemia (<50mg/dL) was observed in 6 (7%) patients. SSI at 30 days was more common after INFRA bypass (n=15, 29%) than OAAA repair (n=2, 6%) (P=0.01). In-hospital (6% vs. 6%, P=1.0) and 30-day (24% vs. 22%, P=1.0) SSI rates were similar for optimal versus suboptimal glycemic control patients after INFRA bypass. In-hospital (4% vs. 0%, P=1.0) and 30-day (4% vs. 0%, P=1.0) SSI rates were similar for optimal versus suboptimal glycemic control patients after OAAA repair. The percentage of blood glucose > 250mg/dL was similar for patients with and without SSI (3% vs. 2%, P=0.36). Adverse cardiac and pulmonary events after INFRA bypass were similar between groups (9%vs. 21%, P=0.23; 0% vs. 5%, P=0.36, respectively). Adverse cardiac and pulmonary events after OAAA repair were similar between groups (2% vs. 0%, P=1.0; 4% vs. 0%, P=1.0, respectively). Mean LOS was significantly lower in patients with optimal glycemic control after INFRA bypass (4.2 vs. 7.3days, P=0.02). Mean LOS was similar after OAAA repair for patients with optimal and suboptimal control (5.8 vs. 6.4days, P=0.46). Inpatient hospital costs after INFRA bypass were lower for the group with optimal (median $25,012, interquartile range [IQ] range $21,726-28,331) versus suboptimal glycemic control (median $28,944, IQ range 24,773-41,270, P=0.02). Postoperative hyperglycemia is common after INFRA bypass and OAAA repair and can be effectively ameliorated with an insulin infusion protocol. The protocol was low risk with reduced LOS and cost after INFRA bypass. Complications including SSI were not reduced in patients with optimal perioperative glycemic control.

Stenotrophomonas maltophilia healthcare-associated infections: identification of two main pathogenic genetic backgrounds

Stenotrophomonas maltophilia is an opportunistic multi-drug-resistant bacterium responsible for healthcare-associated infections. Strategies for in-hospital infection control and management of carriers and environmental reservoirs remain controversial. To determine the population structure of S.maltophilia strains in hospitalized infected patients and to identify putative highly pathogenic subpopulations that require upgraded infection control measures. Eighty-three diverse human strains of various clinical origins from 18 geographically distant hospitals were characterized phenotypically and genotypically using a multi-locus sequence typing (MLST) approach. Neither a predominant nor emerging sequence type (ST) was identified. Among the 80 typeable strains, only 29% corresponded to described STs, especially ST5 (N=6) and ST4/26/31 (N=2). The ST distribution and the phylogenic tree based on the concatenated MLST genes did not account for geographical, clinical origin or antimicrobial susceptibility clustering. A phylogenic tree that included 173 ST profiles from the MLST database and the 80 typeable strains confirmed the high genetic diversity of S.maltophilia, the previously reported genogroup organization and the predominance of genogroup 6, as it represented 41% (33/80) of the strains. Unexpectedly, genogroup 2 was the second most prevalent genogroup and included 16% (13/80) of the strains. These genogroups represented 57% (20/35) of the strains in respiratory patients and 75% (9/12) of the strains in patients with cystic fibrosis. Beyond MLST, the over-representation of some genogroups among strains responsible for healthcare-associated infections was confirmed. Genogrouping affiliation is recommended to implement infection control measures selectively for the most pathogenic strains isolated from patient or environmental reservoirs.

Improvement of infection control management by routine molecular evaluation of pathogen clusters

BackgroundUndetected pathogen clusters can often be a source of spreading in-hospital infections. Unfortunately, detection of clusters can be problematic because epidemiological connection is not always easily established. Infection prevention and control (IPC) measures, however, are most effective when applied at the earliest possible stage. AimThe goal of our study was to evaluate the benefits of routine use of molecular typing techniques for IPC management in a large University teaching hospital. MethodsWe implemented daily routine molecular typing of pathogen clusters using cost-effective standard methods such as random amplified polymorphic DNA PCR, multiple-locus variable number tandem repeat analysis, and spa-typing over a 4-year study period (2012–2015). FindingsFour pathogen clusters were evaluated: (I) 14 cases of Clostridium difficile in a peripheral ward, (II) 17 cases of methicillin-resistant Staphylococcus aureus (MRSA) in two intensive-care units (ICUs), (III) 21 cases of multidrug-resistant Klebsiella pneumoniae within one department, and (IV) 6 cases of vancomycin-resistant Enterococcus faecium in an interdisciplinary ICU. Typing revealed that cluster I was not caused by an outbreak strain but was likely due to different endogenous infections. Clusters III and IV showed a classical space–time clustering of point source outbreaks. Cluster II represented a prolonged temporal cluster, which would have gone undetected without molecular typing because of large intercase intervals. ConclusionImplementing daily routine molecular typing is effective for detecting and analyzing pathogen clusters. Falsely suspected outbreaks can be quickly resolved, whereas actual outbreaks can be identified faster, so that targeted IPC measures can be applied earlier.

The Impact of Nurse Staffing Level on In-hospital Death and Infection in Cancer Patients Who Received Surgery

본 연구의 목적은 의료기관 간호사 확보수준이 수술한 암환자의 원내 사망과 원내 감염에 어떠한 영향을 미치는지 알아보고자 하였다. 이차자료를 이용하였으며, 2012년 상반기에 260개 의료기관에서 수술 후 사망률이 높은 6개 암으로 수술 받은 암환자 24,510명을 대상으로 하였다. 단순 로지스틱 회귀분석과 일반화추정방정식(GEE) 모형을 이용하여 분석하였다. 환자 및 의료기관 특성(기관 종별 유형, 소재지, 수술건수)을 보정 후, 사망 가능성은 간호사 확보수준 0-1등급에 비해 2-3등 급 군(odds ratio [OR], 1.46; 95% confidence interval [CI], 1.00-2.11), 6-7등급 군(OR, 3.28; 95% CI, 1.87-5.74)에서 더 높은 것으로 나타났다. 병원 감염이 발생할 가능성은 간호사 1인당 침상수가 하나씩 증가할 때마다 증가하여, 0-1등급 군에 비해 2-3등급 군은 6.63배(95% CI, 3.00-14.62), 4-5등급 군은 5.79배(95% CI, 1.88-17.78), 6-7등급 군은 8.4배(95% CI, 1.82-38.84) 높은 것으로 나타났다. 낮은 간호사 확보수준은 환자안전과 의료의 질을 반영하는 지표인 높은 수술 후 원내 사망과 감염 발생과 관련이 있었다. 이는 적절한 간호사 확보 수준은 수술 후 암 환자 결과와 관련 있음을 보여준다. 수술한 암환자의 의료의 질 향상과 환자 안전을 위해서는 적절한 간호사 수가 확보되어야 하며, 이를 위한 정책 유지가 필요하다.

Dalbavancin: A New Pathway for the Treatment of Acute Bacterial Skin and Skin Structure Infections in Portugal

Background: Acute bacterial skin and skin structure infections are frequent in-hospital infections. Vancomycin and linezolid are antibacterial agents commonly used in serious acute bacterial skin and skin structure infections but have been associated to prolonged length of stay. Dalbavancin is a new lipoglycopeptide antibacterial, active against Gram positive pathogens, with a long half-life, allowing for a single infusion of 1500 mg or 1000 mg followed one week later by 500 mg. The aim of this study was to assess the effect of dalbavancin on length of stay and mortality of acute bacterial skin and skin structure infections patients in Portugal.Methods and findings: we have modelled the natural history and treatment implications of acute bacterial skin and skin structure infections using a decision analytical tree that calculated the probability of success, failure or death for dalbavancin and linezolid. Efficacy endpoints were obtained from a randomized controlled trial. LOS and mortality due to acute bacterial skin and skin structure infections were derived from non-experimental studies.Conclusion: we estimated the average length of stay for dalbavancin in 10.4 days. Compared to linezolid this represents a 9.4 day reduction. Dalbavancin is estimated to decrease the death rate by 1.7% in serious acute bacterial skin and skin structure infections caused by Gram positive pathogens and by 1.8% in acute bacterial skin and skin structure infections caused by methicillin-resistant Staphylococus aureus.

Detección de genes BLA en aislados clínicos de Escherichia coli provenientes de pacientes del Hospital Nacional Zacamil de El Salvador

La producción de enzimas inactivantes tipo Betalactamasas es uno de los mecanismos más importantes de resistencia antimicrobiana reportado a nivel mundial. Las infecciones ocasionadas por microorganismos productores de Betalactamasas de espectro extendido se relacionan con mayor mortalidad. Debido a la capacidad de diseminarse a través de elementos transponibles, los genes bla se reportan ampliamente. Sin embargo, existen países sin reportes de la circulación de éstos, a pesar de su importancia clínica.Este estudio provee las primeras evidencias de infecciones por Gram negativos intrahospitalarios asociados a genes de betalactamasas en El Salvador. Objetivo: Determinar la presencia de genes bla tipo TEM, SHV, CTX-M1-2 y AmpC en aislados clínicos de Escherichia coli provenientes de pacientes del Hospital Nacional Zacamil. Método: Se estudiaron 30 aislados consecutivos de Escherichia coli provenientes de pacientes durante el periodo de enero a mayo del 2015. La confirmación de especie y determinación de resistencia, se realizó con PromptTM Inoculation Sistem-D para equipo MicroScan®. La producción de BLEE se determinó por método de sinergia de doble disco. Se verificó la presencia de genes bla por medio de Reacción en Cadena de las Polimerasas. Resultados: 24 muestras resultaron positivas a BLEE determinado por método de Doble Disco y 20 por método automatizado MicroScan®. Siendo más efcaz el método de doble disco para la determinación fenotípica de producción de BLEE. Ciprofloxacina y cefriazona fueron los antibióticos más utilizados como tratamiento. Conclusión: El 36.6% de aislados resultó positivo a genes bla tipo TEM. Se obtuvo resultados negativos a los otros genes estudiados.CREA CIENCIA Vol. 10 No 2 ISSN1818-202X julio-diciembre 2016, p. 6-18

Impact of Glucose Management Team on Outcomes of Hospitalization in Patients With Type 2 Diabetes Admitted to the Medical Service

To improve glycemic control of hospitalized patients with diabetes and hyperglycemia, many medical centers have established dedicated glucose management teams (GMTs). However, the impact of these specialized teams on clinical outcomes has not been evaluated. We conducted a retrospective study of 440 patients with type 2 diabetes admitted to the medical service for cardiac or infection-related diagnosis. The primary endpoint was a composite outcome of several well-recognized markers of morbidity, consisting of: death during hospitalization, transfer to intensive care unit, initiation of enteral or parenteral nutrition, line infection, new in-hospital infection or infection lasting more than 20 days of hospitalization, deep venous thrombosis or pulmonary embolism, rise in plasma creatinine, and hospital re-admissions. Medical housestaff managed the glycemia in 79% of patients (usual care group), while the GMT managed the glycemia in 21% of patients (GMT group). The primary outcome was similar between cohorts (0.95 events per patient versus 0.99 events per patient in the GMT and usual care cohorts, respectively). For subanalysis, the subjects in both groups were stratified into those with average glycemia of <180 mg/dL versus those with glycemia >180 mg/dL. We found a significant beneficial impact of glycemic management by the GMT on the composite outcome in patients with average glycemia >180 mg/dL during their hospital stay. The number of patients who met primary outcome was significantly higher in the usual care group (40 of 83 patients, 48%) than in the GMT-treated cohort (8 of 33 patients, 25.7%) (P<.02). Our data suggest that GMTs may have an important role in managing difficult-to-control hyperglycemia in the inpatient setting. BG = blood glucose GMT = glucose management team HbA1c = hemoglobin A1c ICU = intensive care unit POC = point of care T2D = type 2 diabetes.

Epidemiology and biomolecular characterization of carbapenem-resistant klebsiella pneumoniae in an Italian hospital.

To describe the occurrence of CRKP infections in a tertiary care hospital and to analyse the allelic profiles of the clinical strains involved and the most frequent carbapenemases. The study analyzed cases of infection due to CRKP in the period 2013-2014; 147 cases were recorded, most of which (82.31%) were in-hospital infections. A hospital in northern Italy. We retrospectively collected: data on patient characteristics and the microbiological characteristics of CRKP. Isolates from 72 of the in-hospital cases underwent molecular typing (MLST); in addition, in each isolate, a procedure for the detection of the blaKPC gene was carried out. The in-hospital death rate was 24.0% in 2013 and 37.5% in 2014. However, the difference between these two values did not prove statistically significant (P > .05). Analysis of mortality revealed that bloodstream infections were more frequently associated with death than other infections (χ2 = 14.57, P < .001). The age-adjusted Cox proportional hazard model revealed that the patients with bacteremia due to CRKP had a 3-fold higher risk of death (HR 3.11; 95% CI 1.66 - 5.84, P< .001) than those with infections of other sites. MLST revealed that the prevalent allelic profile was ST 512 (79.62%); the most frequent carbapenemase was KPC-3 (83.8%). Our results are in line with those of recent studies, which have shown that the spread of CRKP in Italy is a matter of concern and that further efforts have to be made to prevent the potential dissemination of carbapenemase-producing clones of K. pneumoniae, whenever possible.

Temporal trends in transcatheter aortic valve implantation, 2008-2014: patient characteristics, procedural issues, and clinical outcome.

About a decade past the first transcatheter aortic valve implantation (TAVI), data are limited regarding temporal trends accompanying its evolution from novel technology to mainstream therapy. We evaluated these trends in a large multicenter TAVI registry. TAVI is changing and improving with time. Patients who underwent TAVI between January 2008 and December 2014 at 3 high-volume Israeli centers were divided into 5 time quintiles according to procedure date. Outcomes were analyzed and reported according to Valve Academic Research Consortium-2. A total of 1285 patients were studied (43% male; mean age, 83 ± 3 years; mean Society of Thoracic Surgeons [STS] score, 5.5 ± 3.6). Over time, there was a shift toward treating patients at lower STS score, increased use of conscious sedation and transfemoral approach, and decreased use of balloon predilatation. The balloon-expandable to self-expandable valve utilization ratio decreased, the valve-in-valve experience increased from 4% to 17% of all TAVI volume, and length of hospital stay was halved (P = 0.006). Kaplan-Meier survival curves showed gradual decrease in mortality risk (P = 0.031), but there was no significant 1-year mortality decrease by multivariable analysis. Each year increment was associated with an adjusted 20%, 15%, and 12% decrease in new pacemaker obligation (P = 0.004), new pacemaker obligation or left bundle branch block (P = 0.008), and in-hospital infections (P = 0.082), respectively. Temporal trends accompanying TAVI evolution include its utilization in lower-risk patients, procedural simplification, improved overall survival, decreased pacemaker obligation, and shorter hospital stay.

2016 Influenza epidemics: clinical and epidemiological features and current abilities for effective treatment (according to data from the Clinical Infectious Diseases Hospital No. 1, Moscow)

The aim of this study was to monitor in-hospital influenza virus infection during 2015 – 2016 epidemic flu season. Methods. Influenza virus was searched in patients hospitalized to a clinical infectious diseases hospital with acute respiratory viral infection during 2015 – 2016 influenza seasonal growth period using real-time RT-PCR method. Influenza virus was isolated from nasal swabs and autopsy material using canine kidney cell line. Other laboratory methods used included complete blood count, blood chemistry, blood gas analysis, urinalysis, and chest X-ray examination. Results. We examined 1,491 patients (375 adults, 546 children, 570 pregnant women with early gestational age). The proportion of hospitalized patients with confirmed A / H1N1pdm09 influenza in January – February, 2016, was 91.3%. A / H3N2 influenza virus was diagnosed in 5.7%, influenza B virus was isolated in 1.2% of patients. Totally, influenza virus was detected in 35.2% of samples, of which 30.1% of samples were obtained from adults, 33.7% of samples were obtained from children, and 39.8% of samples were obtained from pregnant women. The prevalent patient’s age was 15 to 60 years (76.1%) in adults and 3 to 6 years in children. Moderate course of influenza with a high rate of hospital admission was seen more often and was similar to that of 2009 – 2010 epidemic season. Proportion of patients with flu complicated by pneumonia was higher than that in 2014 – 2015 epidemic season. Bilateral lung injury was diagnosed in 48.4% of patients. High mortality in ICU (46.4%) was due to delayed start of antiviral treatment and late admission to a hospital. Conclusion. In 2015 – 2016 epidemic flu season, higher morbidity, complications and poor outcomes were related to predominant infection of A – H1N1pdm09 influenza virus. Risk factors of complications and death were delayed care seeking, lack of modern antiviral medications and comorbidity.

Iron supplementation to treat anaemia in adult critical care patients: a systematic review and meta-analysis.

BackgroundAnaemia affects 60–80 % of patients admitted to intensive care units (ICUs). Allogeneic red blood cell (RBC) transfusions remain the mainstay of treatment for anaemia but are associated with risks and are costly. Our objective was to assess the efficacy and safety of iron supplementation by any route, in anaemic patients in adult ICUs.MethodsElectronic databases (CENTRAL, MEDLINE, EMBASE) were searched through March 2016 for randomized controlled trials (RCT)s comparing iron by any route with placebo/no iron. Primary outcomes were red blood cell transfusions and mean haemoglobin concentration. Secondary outcomes included mortality, infection, ICU and hospital length of stay, mean difference (MD) in iron biomarkers, health-related quality of life and adverse events.ResultsFive RCTs recruiting 665 patients met the inclusion criteria; intravenous iron was tested in four of the RCTs. There was no difference in allogeneic RBC transfusion requirements (relative risk 0.87, 95 % confidence interval (CI) 0.70 to 1.07, p = 0.18, five trials) or mean number of RBC units transfused (MD -0.45, 95 % CI -1.34 to 0.43, p = 0.32, two trials) in patients receiving or not receiving iron. Similarly, there was no difference between groups in haemoglobin at short-term (up to 10 days) (MD -0.25, 95 % CI -0.79 to 0.28, p = 0.35, three trials) or mid-term follow up (last measured time point in hospital or end of trial) (MD 0.21, 95 % CI -0.13 to 0.55, p = 0.23, three trials). There was no difference in secondary outcomes of mortality, in-hospital infection, or length of stay. Risk of bias was generally low although three trials had high risk of attrition bias; only one trial had low risk of bias across all domains.ConclusionIron supplementation does not reduce RBC transfusion requirements in critically ill adults, but there is considerable heterogeneity between trials in study design, nature of interventions, and outcomes. Well-designed trials are needed to investigate the optimal iron dosing regimens and strategies to identify which patients are most likely to benefit from iron, together with patient-focused outcomes.Trial registrationPROSPERO International prospective register of systematic reviews CRD42015016627. Registered 2 March 2015.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-016-1486-z) contains supplementary material, which is available to authorized users.

Hypoxemia is an independent predictor of bronchiolitis obliterans following respiratory adenoviral infection in children.

Bronchiolitis obliterans (BO) is an uncommon and severe sequela of chronic obstructive lung disease in children that results from an insult to the lower respiratory tract. Few prognostic factors achieved worldwide acknowledgment. In the present study, we retrospectively collected the children with respiratory adenoviral infection and identified the predictive factors of BO. In the period between Jan 2011 and December 2014, the consecutive in-hospital acute respiratory infection children with positive result for adenovirus were enrolled into the present study. High resolution computerized tomography and clinical symptoms were utilized as the diagnostic technique for BO. Multivariate analysis using a Logistic proportional hazards model was used to test for independent predictors of BO. A total of 544 children were included with 14 (2.57 %) patients developed BO. Compared with children without BO, BO children presented higher LDH (523.5 vs. 348 IU/ml, p = 0.033), lower blood lymphocyte count (2.23 × 109/L vs. 3.24 × 109/L, p = 0.025) and higher incidence of hypoxemia (78.6 vs. 20.8 %, p = 0.000). They presented relatively persistent fever (15.5 vs. 7 days, p = 0.000) and needed longer treatment in hospital (19.5 vs. 7 days, p = 0.000). Concerning treatment, they were given more intravenous γ-globulin (85.7 vs. 36.8 %, p = 0.000), glucocorticoids (78.6 vs. 24.3 %, p = 0.000) and mechanical ventilation (35.7 vs. 5.5 %, p = 0.001). Multiple analyses determined that hypoxemia was the only independent predictor for BO. The present study identified hypoxemia as the independent predictive factor of BO in adenoviral infected children, which was a novel and sensitive predictor for BO.

The Impact of Surgical Care Improvement Project Measures on In-Hospital Outcomes following Elective Vascular Procedures

As part of the Surgical Care Improvement Project (SCIP), a national quality partnership of organizations including the Centers for Medicare and Medicaid Services and the Centers for Disease Control and Prevention implemented several perioperative guidelines regarding antibiotic, venous thromboembolism (VTE), and beta-blocker prophylaxis for surgical patients. We evaluated the effect of SCIP on in-hospital surgical site infections (SSI), graft infections, VTE, myocardial infarctions (MIs), cardiac complications, mortality, and length of stay following elective major vascular surgery. Using International Classification of Diseases, Ninth Revision (ICD-9) diagnostic and procedure codes, we identified elective open abdominal aneurysm repair (OAR), endovascular aneurysm repair (EVAR), carotid endarterectomy (CEA), major lower extremity amputation, and lower extremity bypass (LEB) procedures in the National Inpatient Sample from 2000 to 2012. Logistic regression and generalized linear models controlling for covariates were used to compare postoperative in-hospital outcomes before and after SCIP implementation (pre-SCIP era 2000-2005 versus post-SCIP era 2009-2012). In the post-SCIP era, the rate of in-hospital SSI following OAR increased from 1.0% to 1.6% (P<0.05). Nonetheless, there were improvements in in-hospital SSI (in EVAR and CEA), graft infections (in OAR, EVAR, and LEB for tissue loss), VTE (in CEA), MI (in EVAR and LEB for tissue loss), cardiac complication (in all procedures except OAR), mortality (in EVAR, CEA, major lower extremity amputation, and LEB for tissue loss), and length of stay (in all procedures except OAR) (all P<0.05). However after adjusting for covariates, SCIP was only associated with reducing SSI in CEA and major lower extremity amputation, graft infections in OAR and LEB for tissue loss, VTE in LEB for claudication or rest pain, mortality in OAR, and length of stay in all procedures except EVAR and CEA. Implementation of SCIP measures was associated with slight improvements in a few in-hospital outcomes following vascular procedures. Additional measures that are more specific to the clinical and technical challenges of treating vascular disease may be more effective for improving the management of vascular patents.

Incidence, Causes, and Impact of In-Hospital Infections After Transcatheter Aortic Valve Implantation

In-hospital infections (IHI) are one of the most common and serious problems after invasive procedures. Transcatheter aortic valve implantation (TAVI) is an increasingly used alternative to surgery in patients with severe symptomatic aortic stenosis. The aim of this study was to determine the incidence, origin, risk factors, and clinical outcomes of IHI after TAVI. A total of 303 consecutive patients with severe aortic stenosis who underwent transfemoral TAVI were included and followed during a median time of 21months. We examined the occurrence, types, origin, and timing of infections during hospital stay as well as short- and long-term clinical outcomes according to the occurrence of IHI. A total of 51 patients (17%; 62 infectious episodes) experienced IHI after TAVI. Respiratory and urinary tract infections were the most frequent type of infections (44% and 34%, respectively), followed by surgical site infection (8%) and bloodstream infection (5%). Positive cultures were obtained in 74% of the samples, of which 65% were gram-negative bacilli. Modifiable factors such as bleeding (p= 0.005) and length of coronary care unit stay (p <0.001) were independently associated with an increased infection risk. Patients with IHI had a longer hospital stay (14 vs 6days, p <0.001), an increased mortality (hazard ratio 2.48, 95% CI 1.45 to 4.23) and readmission rate (hazard ratio 2.0, 95% CI 1.27 to 3.14) during the follow-up. In conclusion, IHI is a frequent complication after TAVI with a significant impact onshort- and long-term clinical outcomes. The most important risk factors associated with the development of this complication were modifiable periprocedural aspects. These resultsunderline the importance to implement specific preventive strategies to reducein-hospital-acquired infections after TAVI.