In-hospital Infection Research Articles

Assessing the development and implementation of the Global Trigger Tool method across a large health system in Sicily.

Background: The Institute for Healthcare Improvement (IHI) has proposed a new method, the Global Trigger Tool (IHI GTT), to detect and monitor adverse events (AEs) and provide information to implement improvement. In 2015, the Sicilian Health System adopted IHI GTT to assess the number, types and severity levels of AEs. The GTT was implemented in 44 of 73 Sicilian public hospitals and 18,008 clinical records (CRs) were examined. Here we present the standardized application of the GTT and the preliminary results of 14,706 reviews of CRs. Methods: IHI GTT was adapted, developed and implemented to the local context. Reviews of CRs were conducted by 199 professionals divided into 71 review teams consisting of three individuals: two of whom had clinical knowledge and expertise, and a physician to authenticate the AE. The reviewers entered data into a dedicated IT-platform. All 44 of the public hospitals were included, with approximately 300,000 yearly inpatient admissions out of a population of approximately 5 million. In total, 14,706 randomized CRs of inpatients from medicine, surgery, obstetric and ICU wards, from June 2015 to June 2018 were reviewed. Results: In 975 (6.6%) CRs at least one AE was found. Approximately 20,000 patients of the 300,000 discharged each year in Sicily have at least one AE. In 5,574 (37.9%) CRs at least one trigger was found. A total of 1,542 AEs were found. The analysis of ROC curve shows that the presence of two triggers in a CR indicates with high probability the presence of an AE. The most frequent type of AE was in-hospital related infection. Conclusions: The GTT is an efficient method to identify AEs and to track improvement of care. The analysis and monitoring of some triggers is important to prevent AEs. However, it is a labor-intensive method, particularly if the CRs are paper-based.

How to prevent in-hospital COVID-19 infection and reassure women about the safety of pregnancy: Experience from an obstetric center in China.

ObjectiveThis study aimed to describe the emergency responses to coronavirus disease 2019 (COVID-19) for pregnant patients at our hospital and their effect on hospital operations and patients’ outcomes.MethodsWe developed strategies to prevent hospital-associated transmission of COVID-19 in obstetric care. Infrastructure, including the fever clinic and wards, were modified. Outpatient volume was controlled and screening processes were strictly performed. Verification of the virus was compulsory for non-surgery and non-emergency patients. Emergency operations were performed in a negative pressure theater with surgeons fully protected. Outcomes were analyzed and the patients’ characteristics were evaluated. The effect of intervention on depressed and anxious patients was assessed. Data from the first 2 months of 2019 and 2020 were compared.ResultsNo in-hospital COVID-19 infections occurred in our unit. During the epidemic, patient volume significantly decreased. While major characteristics of patients were similar, a higher prevalence of gestational hypertension was found in 2020 than in 2019. Psychological interventions showed optimistic effects in ameliorating depression and anxiety at the beginning of the COVID-19 pandemic.ConclusionsOur strategies were effective in preventing in-hospital infection of COVID-19 and reassuring women about the safety of pregnancy. Monitoring and managing psychological issues were necessary during this critical period.

Cooling as an Adjunctive Therapy to Percutaneous Intervention in Acute Myocardial Infarction: COOL-MI InCor Trial.

Endovascular Therapeutic hypothermia (ETH) reduces the damage caused by postischemia reperfusion injury syndrome in cardiopulmonary arrest and has already established its role in patients with sudden death; however, its role in ST-segment elevation myocardial infarction (STEMI) remains controversial. The objectives of this study were to investigate the safety, feasibility, and 30-day efficacy of rapid induction of therapeutic hypothermia as adjunctive therapy to percutaneous coronary intervention (PCI) in patients with anterior and inferior STEMIs. This was a prospective, controlled, randomized, two-arm, prospective, interventional study of patients admitted to the emergency department within 6 hours of angina onset, with anterior or inferior STEMI eligible for PCI. Subjects were randomized to the hypothermia group (primary PCI+ETH) or to the control group (primary PCI) at a 4:1 ratio. The ETH was induced by 1 L cold saline (1-4°C) associated with the Proteus™ System, by cooling for at least 18 minutes before coronary reperfusion with a target temperature of 32°C ± 1°C. Maintenance of ETH was conducted for 1-3 hours, and active reheating was done at a rate of 1°C/h for 4 hours. Primary safety outcomes were the feasibility of ETH in the absence of (1) door-to-balloon (DTB) delay; (2) major adverse cardiac events (MACE) within 30 days after randomization. The primary outcomes of effectiveness were infarct size (IS) and left ventricular ejection fraction (LVEF) at 30 days. An as-treated statistical analysis was performed. Fifty patients were included: 35 (70%) randomized to the hypothermia group and 15 (30%) to the control group. The mean age was 58 ± 12 years; 78% were men; and associated diseases were 60% hypertension, 42% diabetes, and 72% dyslipidemia. The compromised myocardial wall was anterior in 38% and inferior in 62%, and the culprit vessels were left anterior descending artery (LAD) (40%), right coronary artery (38%), and left circumflex (18%). All 35 patients who attempted ETH (100%) had successful cooling, with a mean endovascular coronary reperfusion temperature of 33.1°C ± 0.9°C. The mean ischemic time was 375 ± 89.4 minutes in the hypothermia group and 359.5 ± 99.4 minutes in the control group. The mean DTB was 92.1 ± 20.5 minutes in the hypothermia group and 87 ± 24.4 minutes in the control group. The absolute difference of 5.1 minutes was not statistically significant (p = 0.509). The MACE rates were similar between both groups (21.7% vs. 20% respectively, p = 0.237). In the comparison between the hypothermia and control groups, no statistically significant differences were observed at 30 days between mean IS (13.9% ± 8% vs. 13.8% ± 10.8%, respectively, p = 0.801) and mean final LVEF (43.3% ± 11.2% vs. 48.3 ± 10.9%, respectively; p = 0.194). Hypothermia as an adjunctive therapy to primary PCI in STEMI is feasible and can be implemented without delay in coronary reperfusion. Hypothermia was safe regarding the incidence of MACE at 30 days. However, there was a higher incidence of arrhythmia and in-hospital infection in the hypothermia group, with no increase in mortality. Regarding efficacy, there was no difference in IS or LVEF at 30 days that would suggest additional myocardial protection with ETH. ClinicalTrials.gov: NCT02664194.

COVID-19 Pandemisi Sırasında Türkiye’de Acil Servislerin Organizasyonu ve Değişen Hasta Profili

COVID-19 salgını sırasında acil servisler hastaların tanımlanması, izolasyonu, hastane içi enfeksiyonları önlenme ve halk sağlığı otoritelerini bilgilendirmede önemli görevler üstlenir. Olası olgunun hızlı tanımlanması ve diğer hastalardan izole edilmesi gereklidir. Acil servisler doğası gereği afet durumlarında dahi hasta alımının devam etmesi gereken bakım alanlarıdır ve birçok ülkede acil servisler normal rutinlerinde maksimum kapasite ile çalışmaktadır. Tüm bu nedenlerle sağlık merkezlerinde yayılmayı önlemek ve kontrol altına almak için, özellikle acil servislerde kalabalıklığın önlenmesi ve mümkünse hastaların hastane başvurusundan önce tanımlanmasına yönelik politikalar gereklidir. Bu çalışmada COVID-19 Pandemisi ile birlikte bir üniversite hastanesi acil servisinin organizasyonun nasıl düzenlendiği paylaşılmış, acil servise başvuran acil, enfekte hasta ve adli olguların organizasyonu anlatılmıştır.

Complex relationship between low albumin level and poor outcome after lower extremity procedures for peripheral artery disease

ObjectiveA low albumin level has been associated with poor outcome, including death, in surgical patients. The mechanistic relationship, however, is more complex than simply nutritional. As studies are scant in the vascular population, we sought to examine the association of low albumin level with outcomes in patients undergoing open and endovascular lower extremity procedures for peripheral artery disease. MethodsPatients with peripheral artery disease undergoing lower extremity procedures (2008-2015) were selected from Cerner Health Facts database (Cerner Corporation, Kansas City, Mo) using International Classification of Diseases, Ninth Revision diagnosis and procedure codes. Age, sex, disease severity, and other comorbidities were captured. Outcomes were identified using codes and encounter data. A χ2analysis and multivariable logistic regression were performed. ResultsThere were 6170 patients evaluated; 4562 (74%) underwent endovascular procedures and 1608 (26%) underwent open surgery. Low albumin level (<3.5 g/dL) was associated with age ≥80 years (23.1% vs 16.3% normal; P < .0001), black race (21% vs 11.6% normal; P < .0001), tissue loss (38% vs 16.4% normal; P < .0001), and higher Charlson index (mean, 3.1 vs 2.2 in the normal group; P < .0001). Low albumin level was also associated with longer length of stay (4.9 vs 2.2 days normal; P < .0001), higher in-hospital mortality (1.9% vs 0.3% normal; P < .0001), and higher 30-day readmission (15% vs 12.7% normal; P = .02). Multivariable analysis demonstrated that low albumin level was strongly associated with in-hospital death (odds ratio [OR], 5.23; 95% confidence interval [CI], 2.00-13.70), infection (OR, 2.51; 95% CI, 1.96-3.22), renal failure (OR, 2.61; 95% CI, 1.79-3.79), and cardiac complications (OR, 2.59; 95% CI, 1.69-3.96). After multivariable adjustment, there was no association between albumin level and 30-day readmission. ConclusionsLow preoperative albumin levels are associated with in-hospital death, prolonged length of stay, and severe morbidity after open and endovascular lower extremity procedures. As the majority of lower extremity procedures are elective, serious consideration should be given to deferring elective procedures until albumin levels have been optimized. Because of the pleiotropic effects of albumin, including antiplatelet and inflammatory function, study of this complex relationship may offer insights into how best to integrate this novel biomarker into vascular surgery decision-making.

Staffing With Disease-Based Epidemiologic Indices May Reduce Shortage of Intensive Care Unit Staff During the COVID-19 Pandemic.

BACKGROUND:Health care worker (HCW) safety is of pivotal importance during a pandemic such as coronavirus disease 2019 (COVID-19), and employee health and well-being ensure functionality of health care institutions. This is particularly true for an intensive care unit (ICU), where highly specialized staff cannot be readily replaced. In the light of lacking evidence for optimal staffing models in a pandemic, we hypothesized that staff shortage can be reduced when staff scheduling takes the epidemiology of a disease into account.METHODS:Various staffing models were constructed, and comprehensive statistical modeling was performed. A typical routine staffing model was defined that assumed full-time employment (40 h/wk) in a 40-bed ICU with a 2:1 patient-to-staff ratio. A pandemic model assumed that staff worked 12-hour shifts for 7 days every other week. Potential in-hospital staff infections were simulated for a total period of 120 days, with a probability of 10%, 25%, and 40% being infected per week when at work. Simulations included the probability of infection at work for a given week, of fatality after infection, and the quarantine time, if infected.RESULTS:Pandemic-adjusted staffing significantly reduced workforce shortage, and the effect progressively increased as the probability of infection increased. Maximum effects were observed at week 4 for each infection probability with a 17%, 32%, and 38% staffing reduction for an infection probability of 0.10, 0.25, and 0.40, respectively.CONCLUSIONS:Staffing along epidemiologic considerations may reduce HCW shortage by leveling the nadir of affected workforce. Although this requires considerable efforts and commitment of staff, it may be essential in an effort to best maintain staff health and operational functionality of health care facilities and systems.

Outcomes of reperfusion therapy for acute ischaemic stroke in patients aged 90 years or older: a retrospective study.

The benefits and risks of acute reperfusion therapy (RT) in acute ischaemic stroke (AIS) remain uncertain in older patients, especially in nonagenarians. We aimed to assess the impact of RT in this population. Single-center retrospective cohort study comparing patients ≥ 90years old admitted to a Stroke Unit (2008-2018) with AIS, submitted or not to RT [intravenous thrombolysis(IVT), mechanical thrombectomy(MT) or both]. Baseline characteristics, in-hospital complications and 3-month outcomes were compared. The primary outcome was 3-month "favorable outcome", defined as modified Rankin Scale score 0-2 or equal to pre-stroke. Secondary outcomes were haemorrhagic transformation (HT) and 3months mortality. We included 167 patients (median age 92years, 66.5% females); 46.1% underwent RT (59 IVT, 11 MT, 7 both). RT group had higher admission National Institutes of Health Stroke Scale (NIHSS) (16 versus 9.5, p < 0.001). Favorable outcome occurred in only 22% of patients, with no differences between groups; its odds decreased with higher NIHSS scores (OR 0.80, 95%CI 0.73-0.87, p < 0.001) and with the development of in-hospital respiratory infection (OR 0.22, 95%CI 0.07-0.67, p = 0.007). HT occurred in 16.2% of patients, being more prevalent (26.0% versus 7.8%, p = 0.001), symptomatic (14.3% versus 3.3%, p = 0.011) and severe (PH1/2 15.6% versus 2.2%, p = 0.012) in the RT group, although it did not influence the primary outcome. Mortality was 32% at 3months, with no difference between groups. Although patients submitted to RT had worse admission NIHSS and increased HT, they had similar functional outcome at 3months. Stroke severity and in-hospital respiratory infections were the most important predictors of 3months' functional outcome.

Association with Controlling Nutritional Status (CONUT) Score and In-hospital Mortality and Infection in Acute Heart Failure

The high controlling nutritional status (CONUT) score that represents poor nutritional status has been acknowledged to have prognostic implications in chronic heart failure. We aimed to investigate its role in acute decompensated heart failure (ADHF). Using the data from an multicenter registry that enrolled 4056 consecutive patients hospitalized for ADHF in Japan between 2014 and 2016, we analyzed 2466 patients in whom data on the components of the CONUT score at hospital presentation were available. The decrease of lymphocyte count and total cholesterol was assigned with 0, 1, 2, and 3 points and the decrease of albumin was assigned with 0, 2, 4, and 6 points according to the severity. We defined low CONUT score as 0–4 (N = 1568) and high CONUT score as 5–9 (N = 898). The patients in the high CONUT score group were older and more likely to have a smaller body mass index than those in the low CONUT score group. The high CONUT score group was associated with higher rate of death and infection during the index hospitalization compared to the low CONUT score group (9.0% versus 4.4%, and 21.9% versus 12.7%, respectively). After adjusting for confounders, the excess risk of high relative to low CONUT score for mortality and infection was significant (OR: 1.61, 95%CI: 1.05–2.44, and OR: 1.66, 95%CI: 1.30–2.12, respectively). The effect was incremental according to the score. High CONUT score was associated with higher risk for in-hospital mortality and infection in an incremental manner in patients hospitalized for ADHF.

Mortality, complications and long-term functional outcome in elderly patients with fragility fractures of the acetabulum

BackgroundEarly operative treatment of acetabulum fractures in geriatric patients has been suggested to reduce pain and allow for earlier mobilization. The aim of this study was to determine mortality, complications and functional outcome after operative and non-operative treatment.MethodsPatients aged ≥60 years with operative treatment of low-energy fragility fracture of the acetabulum from 2009 to 2016 and a follow-up of at least 24 months were identified. The patients were contacted by phone and a modified Merle d’Aubigné score was obtained. If patients or their relatives were not available for follow-up, mortality data was assessed using a national social insurance database.ResultsOne hundred seventy-six patients (mean age 78, SD 10 years; 73 female) were available for analysis of mortality data. At final follow-up (68 months, SD 26, range, 24 to 129), 99/176 patients (56.3%) had deceased. One-year-mortality was 25.0% and 2-year mortality 35.8%. Type of treatment (non-operative vs. operative) did not affect mortality at 1 and 2 years (p = .65 and p = .10). Hospital-acquired infections were observed in 31/176 cases (17.6%), thromboembolic events and delirium in 6 patients (3.4%). In-hospital mortality was 5.7%. Patients who underwent operative treatment were more likely to have an in-hospital infection (p = .02) but less likely to sustain thromboembolic events (p = .03).The mean hospital stay was 14 days (SD 10 days, range, 1 to 66). Patients with operative treatment were longer hospitalized than patients with non-operative treatment (p < .001).The rate of secondary conversions to THA was 12.4%, this was not affected by initial treatment.The mean modified Merle d’Aubigné Score of those patients available for a final follow-up (n = 47; follow-up 56 months, SD 28, range, 24 to 115) was 14/18 points, SD 3 (range 7 to 18). Functional results at final follow-up between operatively and non-operatively treated patients were without difference.ConclusionsAll-cause mortality and in-hospital complications are high among geriatric patients with low-energy fractures of the acetabulum even when treated operatively. Secondary conversion rates to THA are similar to those seen in younger patients. Mid-term functional outcome in those surviving is fair.

Individualized Red-Cell Transfusion Strategy for Non-Cardiac Surgery in Adults: A Randomised Controlled Trial

Background: We developed an individualized transfusion strategy and it might reduce red-cell requirement without compromising patients' safety as compared with restrictive and liberal strategies for surgery, in order to access the safety and cost-effectiveness of a practical individualized red-cell transfusion strategy by using the West-China-Liu's Score based on the physiology of oxygen delivery/consumption balance. Methods: This open labeled, multicenter, randomised clinical trial was conducted in 35 Chinese Hospitals from May 2012 to January 2016, with follow-up until January 2017. Among 1351 eligible patients undergoing non-cardiac surgeries, 1213 were randomised, 1182 were included in the final analysis. Patients with haemoglobin concentration <10 g per deciliter due to surgical bleeding were randomly assigned to an individualized-strategy (n=379) using the West-China-Liu's Score, a restrictive-strategy (n=419) following China's guideline, or a liberal-strategy (n=384) with transfusion threshold of haemoglobin concentration < 9.5 g per deciliter. There were two primary outcomes. First, the proportion of patients received red-cell (superiority test); Second, a composite of in-hospital complications and all-cause mortality by day-30 (noninferiority test). The secondary outcomes included allogeneic blood cost and total in-hospital cost, all-cause mortality by day-60, day-180 and 1-year, in-hospital complications and infection rate, ICU admission rate, incision healing status and length of hospital stay after surgery. Findings: The main findings were that 30.6% patients in the individualized-strategy received red-cell transfusion, less than 62.4% in the restrictive-strategy (absolute risk difference, 31.92 percentage points; 97.5% confidence interval[CI] 24.42 to 39.42; odds ratio, 3.78; 97.5%CI, 2.7 to 5.3; p<0.001) and 89.8% in the liberal-strategy (absolute risk difference, 59.24 percentage points; 97.5%CI, 52.91 to 65.57; odds ratio, 20.06; 97.5%CI, 12.74 to 31.57; p<0.001), and no differences were found for composite of in-hospital complications and mortality by day-30 among the three strategies. Interpretation: The individualized red cells transfusion strategy using the West-China-Liu's Score reduced red-cell transfusion without increase of in-hospital complications and mortality by day-30 when compared with restrictive and liberal strategies in elective non-cardiac surgeries. Trial Registration: The study protocol was registered at http://www.clinicaltrials.gov (NCT01597232). Funding Statement: This trial was funded by National Key R&D Program of China (2018YFC2001800), the 1-3-5 Project for disciplines of excellence, West China Hospital, and the Sichuan University Education Foundation. Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: This study protocol has been first approved by the Biological- Medical Ethical Committee of West China Hospital, Sichuan University, Chengdu, Sichuan, China on 10 January 2012, and then approved by all the participating centers successively.

Abstract WP338: The Impact of Social Determinants of Health on 30-Day Readmission After Ischemic Stroke

Objective: Readmission after ischemic stroke presents immense social and financial burden on the patient, family and society. The impact of social determinants of health on post-stroke readmission have not been well studied. This study aimed to examine association of patient social determinants with 30-day readmission risk after ischemic stroke. Methods: We examined patients who were hospitalized for acute ischemic stroke (ICD-9 codes 433.1, 434, and 436) in the state of Florida and New York from February 2012 to November 2013, with a 30-day run-in time and 30-day follow up time. Data were obtained from the State Inpatient Database which was then linked with Census data on social determinants at zip code level. Multivariate logistic regression models were generated to study the association of patient factors with 30-day readmission, after adjusting for patient characteristics, in-hospital infection, hemiplegia, and 16 comorbidities. All statistical analyses were conducted using SAS Version 9.4 software (SAS Institute). Results: A total of 127,290 patients were included in the study. The overall 30-day readmission rate was 23%. The 30-day readmission rates differed by race, insurance but not age, sex or household income at zip code level. The 30-day readmission rate was higher amongst black (27%) and Hispanics (25%), and lower in Native American (17%) and White (22%). Comparable to older age groups, patients who suffered a stroke at young age (&lt;50 years old) had 23% readmission rates at 30 days. In the multivariate logistic regression model, age was not a risk factor for readmission [adjusted odds ratio (OR) 1.0, 95% confidence interval (CI) 1.0-1.0]. Compared to white, black race had higher risk of 30-day readmission (OR1.2, 95% CI 1.1-1.2), as well as Hispanic race (OR1.1, 95% CI 1.1-1.2). Compared to Medicare insurance, patient on Medicaid had higher risk of 30-day readmission (OR 1.1, 95% CI 1.1-1.2). Self-pay patients had lower risk of readmission (OR 0.6, 95% CI 0.5-0.7). Conclusion: Race and medical insurance, not age, sex, or household income, has significant influence in30-day readmission risk after ischemic stroke. This will allow further targeted intervention for readmission reduction.

Abstract TP322: The Selection of Enteral Nutrition in Stroke Influence on In-Hospital Infection Control and Hospital Cost

Background: Infection is a common complication after stroke and is strongly associated with an unfavorable functional outcome of patients. Although nutritional intervention reduces the risk of post-operative infection, the impact of differences of products has not been clarified. Less examination of infection and use of antibiotics not only show a high-quality care. In DPC hospital (Japanese style of DRG / PPS), it is important from the hospital management point of view to reduce the comprehensive costs such as medicines and inspections as much as possible. The purpose of this study is to investigate whether the selection of enteral nutrition in the acute phase of stroke patients can contribute to inflectional control and hospital costs. Methods: Retrospective analysis in a single center was performed in 50 acute stroke patients who were received enteral nutrition from April 2017 to March 2019. Nutrients gradually over 7 days of hospitalization, the patients were classified into two groups: 1.0-group (general nutrition 1.0 kcal/mL, 25 patients) and 1.5+α-group (started with high protein whey peptide-digested liquid diet (1.5 kcal/mL) and were, later, switched to highly fermentable dietary fiber contained liquid diet (1.5 kcal/mL) after 4 days, 25 patients). Lengths of hospital stay, days of antibiotic use (except during intraoperative), serious infection including methicillin-resistant Staphylococcus aureus , Extended spectrum β -lactamase producing Enterobacteriaceae and Clostridium difficile infection, and total medical costs were analyzed. Results: The baseline characteristics were similar in the both groups. The mean of lengths of hospital stay were 48.0 and 47.8 days in 1.0-group and 1.5+α-group, respectively. The mean of days of antibiotics use during hospitalization in 1.0-group (16.5 days (34.4%)) were larger than that in 1.5+α-group (11.3 days (23.6%)). The serious infections were developed in six and four cases in 1.0-group and 1.5+α-group, respectively. The total hospital costs were reduced by approximately 500 USD/patient in 1.5+α group as compared to 1.0 group. Conclusions: The selection of enteral nutrition in the acute phase of stroke patients affects the risk of in-hospital infection and reduces hospital costs.

Guideline adherence for the management of emergency department patients with febrile neutropenia and no infection source: Is there room for improvement?

Febrile neutropenia is an oncologic emergency associated with significant morbidity and mortality. The objective of our study was to assess guideline adherence and clinical outcomes associated with the management of high- and low-risk febrile neutropenia patients presenting to the emergency department. A retrospective observational cohort study was conducted at a 60,000-visit emergency department at an academically-affiliated tertiary referral hospital. Patients were identified as low- or high-risk using the guideline-recommended Multinational Association for Supportive Care in Cancer score. The primary outcome was the proportion of cases in which the management was concordant with applicable febrile neutropenia guidelines. Guideline adherence was defined as hospital admission and intravenous antimicrobial therapy for high-risk patients and discharge home with oral antimicrobial therapy for low-risk patients. Secondary outcomes included appropriate vancomycin administration, hospital length of stay, rates of acute kidney injury, in-hospital Clostridium difficile infection rates, and 30-day mortality. Of the 237 patients included, 94 (39.7%) were low-risk patients and 143 (60.3%) were high-risk patients. Guideline adherence occurred in 96.8% of high-risk patients and 0.4% of low-risk patients. Mean hospital length of stay of the low-risk group was 5 ± 5.0 days compared to 7.2 ± 7.3 days in the high-risk group. Vancomycin was often inappropriately given in 69.5% of high-risk patients. Clostridium difficile occurred in 15 (10.3%) adherent and 4 (4.4%) non-adherent patients. By 30 days, 4 (4.3%) low-risk and 15 (10.7%) high-risk patients died. Adherence to the febrile neutropenia guidelines was low resulting in unnecessary hospital admissions of low-risk patients and frequent over-prescription of empirical vancomycin.

In-hospital infections in the medical student

In-hospital infections in the medical student

Efficacy and patterns of use of antimicrobial prophylaxis for gunshot wounds in a South African hospital setting: an observational study using propensity score-based analyses

Limited evidence supports the efficacy of antimicrobial prophylaxis (AP) in prevention of gunshot woundrelated (GSW-related) infection in resource restricted areas. At Tygerberg Hospital, South Africa, it is standard care for GSW patients to receive one dose of broad-spectrum AP. For various reasons, this protocol is not consistently followed. This study aimed to assess the efficacy of AP in the reduction of in-hospital GSW-related infection and to identify opportunities for practice improvement. All patients admitted with GSW over a three-month period were eligible for inclusion. Patients who did and did not receive AP were identified retrospectively the morning of admission; thereafter, data was collected prospectively. Data regarding circumstances of the incident, injury characteristics, type of AP and surgery was obtained. The occurrence of in-hospital GSW-related infection was recorded over 30 days or until discharge. Propensity score matching (PSM) and inverse probability weighting (IPW) methods were utilised to assess the effect of AP on the prevention of GSW-related infection. 165 consecutive patients were assessed, of which 103 received AP according to protocol within 12 hours of admission. PSM showed a reduced in-hospital GSW infection risk of 12% (95% CI, 0.2-24%, p = 0.046) with AP. IPW showed that AP reduced the risk for infection by 14% (95% CI, 3-27%, p = 0.015). Providing AP to GSW patients in a civilian setting appeared to result in a modest but clinically relevant lower risk of in-hospital GSW-related infection. In this study setting, optimisation of AP for all patients with GSWs should significantly lower the burden of wound infection.

The Stress-Immune Response in Acute Hyperglycemic Stroke

Diabetic and hyperglycemic stroke patients have worse clinical outcome, higher mortality rates, larger infarcts, and more severe neurological disability than euglycemic individuals. The reasons for the worse outcome in diabetes are poorly understood, but may not be fully explained by hyperglycemia alone. The objective of this prospective clinical study was to explore whether there is an association between the stress-immune response and clinical outcomes in the hyperglycemic state. Circulating immune cells including neutrophils, monocytes, B-cells and subpopulations of T-lymphocytes were measured over 96 hours post stroke in both hyperglycemic and euglycemic patients. Cortisol and C-reactive protein (CRP) were measured daily over 4 days in the acute post-stroke phase. Short- and long-term neurological outcomes were assessed by the NIH stroke scale, modified Ranking scale and discharge disposition. Discharge dispositions were captured at discharge and 90 days post stroke. Data on infection rates and all course mortality were collected during the hospital stay and at 3 months follow up. Hyperglycemic stroke patients had worse clinical outcomes, more in-hospital infections, less favorable discharge dispositions and higher mortality rates. Hyperglycemic individuals had higher cortisol and CRP levels, higher peripheral neutrophil concentrations and suppressed lymphocyte levels compared to their euglycemic counterparts. Our data suggests an altered stress-immune response in the hyperglycemic state following acute ischemic stroke which could contribute to the poor clinical outcome in this high risk group. Key words Key words: Diabetes, hyperglycemia, ischemic stroke, lymphocytes, neutrophils

Implementation of Accompanying Family Management for Gastroenterology Patients During the COVID-19 Epidemic

The objective of this study is to explore the effect of implementing accompanying family management in gastroenterology patients during the COVID-19 epidemic. According to the guidelines for the prevention and control of COVID-19 issued by the National Health Commission and the Guangdong Provincial Health Commission, as well as the First Affiliated Hospital of Jinan University and patients’ demands, we implemented an accompanying family management system for gastroenterology patients. The management plan not only listed the permission criteria for accompanying family, but also offered escorts with COVID-19 nucleic acid testing, COVID-19 case screening, temperature measurement, symptom observation, health education, and health protection. The results of this study revealed the following main findings: From January 23 to April 23, 2020, a total of 438 inpatients and 113 family escorts were admitted to the hospital, who demonstrated 100% compliance with epidemic prevention and control measures, no infections, and an average score of 96.2 in the patient satisfaction survey. It can be concluded that the establishment and strict implementation of an accompanying family management system together with good epidemic prevention and control practices not only substantially reduces the accompanying family rate without compromising the quality and safety of patient care, but also effectively prevents in-hospital infections.

Effectiveness, safety and risk of selection of carbapenem-resistant bacteria in the treatment of severe in-hospital infections with cefepime/sulbactam in comparison with carbapenems

Effectiveness, safety and risk of selection of carbapenem-resistant bacteria in the treatment of severe in-hospital infections with cefepime/sulbactam in comparison with carbapenems

Primary vs delayed primary closure in patients undergoing lower limb amputation following trauma: A randomised control study

Lower limb crush injury is a major source of mortality and morbidity in trauma patients. Complications, especially surgical site infections (SSIs) are a major source of financial burden to the institute and to the patient as it delays rehabilitation. As such, every possible attempt should be made to reduce any complications. We, thus, aimed to compare the outcomes in early vs delayed closure of lower extremity stumps in cases of lower limb crush injury requiring amputation, so as to achieve best possible outcome. A randomised controlled study was conducted in the Division of Trauma Surgery & Critical Care at Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi from 1 September 2018 to 30 June 2019 and included patients undergoing lower limb amputation below hip joint. Patients were randomised in two groups, in one group amputation stump was closed primarily, while in the second group delayed primary closure of stump was performed. We compared rate of SSI, length of hospital stay, and number of surgeries in both the groups. Fifty-six patients with 63 amputation stumps were recruited in the study. Mean age of patients in the study was 34 years, of which about 95% patients were males. The most common mechanism of injury was road traffic injury in 66% of patients. Mean injury severity score was 12.28 and four patients had diabetes preoperatively. Total 63 extremities were randomised with 30 cases in group I and 33 cases in group II as per computer-generated random number. Above knee amputations was commonest (57.14%) followed by below knee amputations (33.3%). Two patients died in the current study. In group I, In-hospital infection was detected in 7 cases (23.3%) and in group II 9 cases (27.3%) had SSI during hospital admission (P > .05). Mean hospital stay in group I was 10.32 ± 7.68 days and in group II was 11 ± 8.17 days (P > .05). Road traffic injuries and train-associated injuries are a major cause of lower limb crush injuries, leading to limb loss. Delayed primary closure of such wounds requires extra number of surgical interventions than primary closure. There is no difference in extra number of surgical interventions required in both the groups. Thus, primary closure can be safely performed in patients undergoing lower limb amputations following trauma, provided that a good lavage and wound debridement is performed.

Postoperative Complications Are Not Elevated in Well-Compensated ESRD Patients Undergoing Cardiac Surgery: End-Stage Renal Disease Cardiac Surgery Outcomes

BackgroundPatients with end-stage renal disease (ESRD) are at high risk for cardiac disease requiring surgery, and have been shown to have increased surgical risks. There have been significant improvements in ESRD management, surgical techniques, and patient selection over the past 10 y. We evaluated rates of serious postoperative outcomes in stable, well-dialyzed patients with ESRD undergoing nonemergent cardiac surgery compared to the general cardiac surgery population. MethodsIn this propensity-score matched study, we evaluated 1451 adult patients who underwent nonemergent cardiac surgery at the University of Colorado Hospital (UCH) between 2011 and 2016. Patients with ESRD were compared to nonESRD patients. The primary outcome was a composite endpoint, including 30-d mortality, stroke, postoperative infection, and prolonged intensive care unit (ICU) length of stay (LOS). ResultsA total of 35 patients with ESRD met inclusion criteria. These select patients were younger with few comorbidities than the nonESRD population. There were no statistically significant differences in the composite outcome between ESRD and nonESRD patients in the propensity-matched analysis (OR 0.70, CI 0.29-1.72, P = 0.44). There were no significant differences or trends for in-hospital mortality, postoperative stroke, infection, ICU LOS, or hospital LOS between the patients with and without ESRD. ConclusionsStable ESRD patients undergoing nonemergent surgery are not at increased risk of major postoperative complications when compared to those without ESRD. Well-compensated ESRD patients should not be excluded from surgical consideration.