Noninfectious Diagnoses Research Articles

Effect of Marijuana Smoking on Pulmonary Disease in HIV-Infected and Uninfected Men: A Longitudinal Cohort Study

SummaryBackgroundLung disease is a common comorbidity in people with HIV/AIDS, independent of smoking status. The effects of marijuana smoking on risk of lung disease in HIV-infected individuals are unclear.MethodsIn this prospective cohort study, we quantified lung disease risk among men enrolled in the Multicenter AIDS Cohort Study (MACS), a long-term observational cohort of HIV-infected and uninfected men who have sex with men. Eligible participants were aged ≥ 30 years with self-reported marijuana and tobacco smoking data from biannual study visits between 1996 and 2014. Pulmonary diagnoses were obtained from self-report and medical records. Analyses were performed using Cox models and Generalized Estimating Equations adjusted for tobacco smoking, CD4 T cell count, and other risk factors.Findings1630 incident pulmonary diagnoses were reported among 1352 HIV-seropositive and 1352 HIV-seronegative eligible participants matched for race and baseline age (53,794 total person-visits, median follow-up 10.5 years). 27% of HIV-infected participants reported daily or weekly marijuana smoking for one or more years in follow-up, compared to 18% of uninfected participants (median 4·0 and 4·5 years daily/weekly use, respectively). HIV-infected participants had an increased likelihood of infectious or non-infectious pulmonary diagnoses compared to uninfected participants (33·2% vs. 21·5%, and 20·6% vs. 17·2%, respectively). Among HIV-infected participants, recent marijuana smoking was associated with increased risk of infectious pulmonary diagnoses and chronic bronchitis independent of tobacco smoking and other risk factors for lung disease (hazard ratio [95% confidence interval] 1·43 [1·09–1·86], and 1·54 [1·11–2·13], respectively); these risks were additive in participants smoking both substances. There was no association between marijuana smoking and pulmonary diagnoses in HIV-uninfected participants.InterpretationIn this longitudinal study, long-term marijuana smoking was associated with lung disease independent of tobacco smoking and other risk factors in HIV-infected individuals. These findings could be used to reduce modifiable risks of lung disease in high-risk populations.FundingU.S. National Institutes of Health.

Kajian Penggunaan, Ketepatan, dan Biaya Antibiotik pada Pasien Rawat Inap Anak di Sebuah Rumah Sakit Umum di Surabaya

An appropriate utilization of antibiotics is one of important aspects to assure treatment effectiveness and safety in all patient groups, especially in patients with distinctive physiology and pharmacokinetic profile. This study aimed to assess the utilization, appropriateness and cost of antibiotics administered in a pediatric hospital ward during November–December 2015. Method used to collect the data was observation conducted prospectively towards all medical records of paediatric inpatients receiving antibiotics during the study period. Medical records of patients receiving prophylaxis antibiotics before surgery, patients discharged against medical advice, and patients suddenly needed medical treatment in a special ward were excluded from the study. Overall, a total of 109 medical records met inclusion and exclusion criteria, in which 82 (75.23%) patients’ age ranged from 1 month to 2 years. There were 5 (4.59%) patients with non-infectious diagnoses and no signs of infection receiving antibiotics. No patients were tested for a microbial culture. The most utilized antibiotic class was the 3rd generation of cephalosporins (114 antibiotics, 90.48%); 63 (55.26%) of which was ceftriaxone. The utilization of antibiotics in 21 (45.65%) patients was considered dose appropriate, in 19 (41.30%) patients were dose-frequency appropriate and in 6 patients was classified as none appropriate. The mean of the cost of antibiotic per patient was IDR 209,731.72. There is a need to optimalize the appropriateness of antibiotic utilization in hospitalized pediatrics at the study hospital. Microbial culture and sensitivity tests would plausibly be one of preliminary steps to guard the appropriateness of antibiotic utilization.

Up to 89% of neonates received antibiotics in cross-sectional Indian study including those with no infections and unclear diagnoses.

There is a global lack of data on antibiotic prescribing for neonates. This study compared antibiotic prescribing practices in the neonatal intensive care units (NICUs) of two private-sector, tertiary-level hospitals. A three-year, cross-sectional study was conducted from 2008 to 2011 in the NICUs of a teaching and nonteaching hospital in the Ujjain district of India. The data were analysed using methods recommended by the World Health Organization. Of the 1789 inpatients, 89% (1399/1572) in the nonteaching hospital and 71% (154/217) in the teaching hospital were prescribed antibiotics and 123 patients died. All the antibiotics were prescribed empirically and cephalosporins and aminoglycosides were the most commonly prescribed subclasses. Fixed-dose combinations of cephalosporins were commonly prescribed in the nonteaching hospital. Neonatal sepsis was the most common diagnosis, in more than 30% of patients, and more than 93% neonates with sepsis were prescribed antibiotics. In addition, 40% of neonates in the nonteaching hospital were admitted for observation and were frequently prescribed antibiotics. These two Indian NICUs prescribed antibiotics for noninfectious or unclear diagnoses in addition to prescribing combinations of broad-spectrum antibiotics. Such practices increase the global risk of treatment failure, neonatal mortality rates and antibiotic resistance.

Early versus late diagnosis in community-acquired bacterial meningitis: a retrospective cohort study

ObjectivesTo examine clinical characteristics and outcome of patients with late diagnosis of community-acquired bacterial meningitis (CABM). MethodsWe conducted a chart review of all adults with proven CABM in three centres in Denmark from 1998 through to 2014. Patients were categorized as early diagnosis of CABM immediately on admission, or late diagnosis if CABM was not listed in referral or admission records and neither lumbar puncture nor antibiotic therapy for meningitis was considered immediately on admission. We used modified Poisson regression analysis to compute adjusted relative risks with 95% CIs for predictors of late diagnosis and in-hospital mortality. ResultsA total of 113/358 (32%) patients were categorized as late diagnosis demonstrating a variety of tentative diagnoses of which 81/113 (72%) were non-infectious. We observed several statistically significant baseline differences (p <0.05) in patients with late versus early diagnosis including age >65 years (56/113, 50% versus 67/245, 27%), neck stiffness (35/97, 36% versus 183/234, 78%), concomitant pneumonia (26/113, 23% versus 26/245, 11%), and meningococcal meningitis (6/113, 5% versus 52/245, 21%). These variables remained statistically significant in multivariate analysis. Moreover, late diagnosis was associated with increased in-hospital mortality (41/113, 36% versus 43/245, 18%; adjusted relative risk 1.7, 95% CI 1.2–2.5). ConclusionsLate diagnosis of CABM was common and patients were admitted with mostly non-infectious diagnoses. Absence of neck stiffness did not rule out CABM and special attention should be given to patients with pneumonia and the elderly. Late diagnosis was associated with incorrect patient management and increased mortality.

Association of Inpatient Antimicrobial Utilization Measures with Antimicrobial Stewardship Activities and Facility Characteristics of Veterans Affairs Medical Centers.

Antimicrobial stewardship programs (ASPs) have been advocated to improve antimicrobial utilization, but program implementation is variable. Antimicrobial stewardship programs (ASPs) have been advocated to improve antimicrobial utilization, but program implementation is variable. To determine associations between ASPs and facility characteristics, and inpatient antimicrobial utilization measures in the Veterans Affairs (VA) system in 2012. In 2012, VA administered a survey on antimicrobial stewardship practices to designated ASP contacts at VA acute care hospitals. From the survey, we identified 34 variables across 3 domains (evidence, organizational context, and facilitation) that were assessed using multivariable least absolute shrinkage and selection operator regression against 4 antimicrobial utilization measures from 2012: aggregate acute care antimicrobial use, antimicrobial use in patients with non-infectious primary discharge diagnoses, missed opportunities to convert from parenteral to oral antimicrobial therapy, and double anaerobic coverage. All 130 VA facilities with acute care services. Variables associated with at least 3 favorable changes in antimicrobial utilization included presence of postgraduate physician/pharmacy training programs, number of antimicrobial-specific order sets, frequency of systematic de-escalation review, presence of pharmacists and/or infectious diseases (ID) attendings on acute care ward teams, and formal ID training of the lead ASP pharmacist. Variables associated with 2 unfavorable measures included bed size, the level of engagement with VA Antimicrobial Stewardship Task Force online resources, and utilization of antimicrobial stop orders. Formalization of ASP processes and presence of pharmacy and ID expertise are associated with favorable utilization. Systematic de-escalation review and order set establishment may be high-yield interventions. Journal of Hospital Medicine 2017;12:301-309.

Nichtinfektiöse Differenzialdiagnosen von Pneumonien

ZusammenfassungHintergrundBei der Verdachtsdiagnose Pneumonie sind die Kombination aus typischer Klinik, Labor und der Nachweis einer Verdichtung in der Röntgenthoraxaufnahme in der Regel diagnostisch und es wird umgehend mit der Therapie begonnen. Studien haben jedoch gezeigt, dass bei bis zu 5 % der Patienten mit Erstverdacht auf Pneumonie eine andere (pulmonale) Erkrankung zugrunde liegt. Ein frühzeitiges Erkennen und eine Differenzierung von Erkrankungen, die eine Pneumonie vortäuschen, sind für die weitere Behandlung essenziell.FragestellungÜbersicht über wesentliche nichtinfektiöse Differenzialdiagnosen der Pneumonie.Material und MethodeEs wurde eine Literaturrecherche durchgeführt.ErgebnisseDa krankhafte Lungenveränderungen oft ähnliche Bilder hervorrufen und anhand der Röntgenthoraxaufnahme oder der CT-Untersuchung nicht zwischen Blut, Transsudat, Exsudat und Zellen differenziert werden kann, ist eine systematische Herangehensweise wesentlich für die Differenzialdiagnose. Dazu werden der zeitliche Verlauf, das prädominante Muster, die Verteilung der Veränderungen, zusätzliche Befunde und die Klinik berücksichtigt.

Increased mortality in hematological malignancy patients with acute respiratory failure from undetermined etiology: a Groupe de Recherche en Réanimation Respiratoire en Onco-Hématologique (Grrr-OH) study.

BackgroundAcute respiratory failure (ARF) is the most frequent complication in patients with hematological malignancies and is associated with high morbidity and mortality. ARF etiologies are numerous, and despite extensive diagnostic workflow, some patients remain with undetermined ARF etiology.MethodsThis is a post-hoc study of a prospective multicenter cohort performed on 1011 critically ill hematological patients. Relationship between ARF etiology and hospital mortality was assessed using a multivariable regression model adjusting for confounders.ResultsThis study included 604 patients with ARF. All patients underwent noninvasive diagnostic tests, and a bronchoscopy and bronchoalveolar lavage (BAL) was performed in 155 (25.6%). Definite diagnoses were classified into four exclusive etiological categories: pneumonia (44.4%), non-infectious diagnoses (32.6%), opportunistic infection (10.1%) and undetermined (12.9%), with corresponding hospital mortality rates of 40, 35, 55 and 59%, respectively. Overall hospital mortality was 42%. By multivariable analysis, factors associated with hospital mortality were invasive pulmonary aspergillosis (OR 7.57 (95% CI 3.06–21.62); p < 0.005), use of invasive mechanical ventilation (OR 1.65 (95% CI 1.07–2.55); p = 0.02), a SOFA score >7 (OR 3.32 (95% CI 2.15–5.15); p < 0.005) and an undetermined ARF etiology (OR 2.92 (95% CI 1.71–5.07); p < 0.005).ConclusionsIn patients with hematological malignancies and ARF, up to 13% remain with undetermined ARF etiology despite comprehensive diagnostic workup. Undetermined ARF etiology is independently associated with hospital mortality. Studies to guide second-line diagnostic strategies are warranted. ClinicalTrials.Gov NCT01172132Electronic supplementary materialThe online version of this article (doi:10.1186/s13613-016-0202-0) contains supplementary material, which is available to authorized users.

Mortality, length of stay, bloodstream and respiratory viral infections in a pediatric intensive care unit

ObjectivesWe investigated whether diagnostic categories and presence of infections were associated with increased mortality or length of stay (LOS) in patients admitted to a pediatric intensive care unit (PICU). MethodsA retrospective study of all PICU admissions between October 2002 and April 2016 was performed. Oncologic vs nononcologic, trauma/injuries vs nontraumatic, infectious (gram-positive, gram-negative, fungal bloodstream infections, common respiratory viruses) vs noninfectious diagnoses were evaluated for survival and LOS. ResultsPediatric intensive care unit admissions (n = 2211) were associated with a mortality of 5.3%. Backward binary logistic regression showed that nonsurvival was associated with leukemia (odds ratio [OR], 4.81; 95% confidence interval [CI], 2.2-10.10; P < .0005), lymphoma (OR, 21.34; 95% CI, 3.89-117.16; P < .0005), carditis/myocarditis (OR, 7.91; 95% CI, 1.98-31.54; P = .003), encephalitis (OR, 6.93; 95% CI, 3.27-14.67; P < .0005), bloodstream infections with gram-positive organisms (OR, 5.32; 95% CI, 2.67-10.60; P < .0005), gram-negative organisms (OR, 8.23; 95% CI, 4.10-16.53; P < .0005), fungi (OR, 3.93; 95% CI, 1.07-14.42; P = .039), and pneumococcal disease (OR, 3.26; 95% CI, 1.21-8.75; P = .019). Stepwise linear regression revealed that LOS of survivors was associated with bloodstream gram-positive infection (B = 98.2; 95% CI, 75.7-120.7; P < .0005). ConclusionsPatients with diagnoses of leukemia, lymphoma, cardiomyopathy/myocarditits, encephalitis, and comorbidity of bloodstream infections and pneumococcal disease were significantly at risk of PICU mortality. Length of stay of survivors was associated with bloodstream gram-positive infection. The highest odds for death were among patients with leukemia/lymphoma and bloodstream coinfection. As early diagnosis of these childhood malignancies is desirable but not always possible, adequate and early antimicrobial coverage for gram-positive and gram-negative bacteria might be the only feasible option to reduce PICU mortality in these patients. In Hong Kong, a subtropical Asian city, none of the common respiratory viruses were associated with increased mortality or LOS in PICU.

P85 Hiv-related Acute Respiratory Admissions - Good Outcomes And An Opportunity For Testing

<h3>Introduction</h3> The burden, changing pattern and outcome of HIV-associated lung disease following the introduction of anti-retroviral therapy (ART) remains to be defined. We sought to investigate these factors in an unselected cohort of individuals admitted acutely to our London teaching hospital. <h3>Methods</h3> Consecutive admissions were prospectively collected between June 2013 and May 2014. In those where the cause for admission was an acute respiratory illness, patient notes and electronic records were interrogated. Patients were allowed &gt;1 diagnoses and in-hospital outcomes only were reported. <h3>Results</h3> Fifty-three of 149 (35%) acute HIV admissions were with respiratory causes, (3 patients had 2 admissions &gt;30 days apart). Median age was 45 years and 28% (15) were female. Median CD4 count was 109 (range 3–867) cells/uL; 14 (26%) had fully suppressed HIV loads (VL &lt;20 copies/ml). 4 of 53 (8%) were admitted with non-infectious diagnoses: 2 with lung cancer, 1 non-infective COPD exacerbation and 1 non-specific interstitial pneumonia. The remainder had infections: 12 (23%) had culture-confirmed bacterial pneumonia, 11 (21%) were treated for PCP, 8 (15%) had culture-confirmed Mycobacterium tuberculosis (1 MDR), 4 had confirmed viral pneumonia (8%). 20 (38%) patients completed treatment for pneumonia with no specific laboratory confirmation. The most common bacterial isolates were streptococcus pneumoniae (4 cases), haemophilus influenzae (3), pseudomonas aureginosa (2) and klebsiella pneumoniae (2). In 11 of 53 (22%) a new diagnosis of HIV was made at the time of admission, 10 of whom presented as acute community acquired pneumonia (CAP). In 9 of 11 (82%) CD4 count was &lt;200 cells/uL and 6 of 11 (55%) required ICU care. In total 20 of 53 (38%) were admitted to ICU, and 8 (15%) required mechanical ventilation. Median length of stay in hospital was 9 (2–397) days. 1 of 53 (2%) patients died. <h3>Conclusions</h3> Acute respiratory illness remains a significant cause of HIV admissions, with opportunistic and non-opportunistic pathogens commonly identified. Outcomes were reassuringly good despite the frequent need for ICU support. We believe our data underlines the important opportunity that a presentation with acute respiratory illness provides to test for and diagnose HIV infection.

What do infectious diseases physicians do? A 2-week snapshot of inpatient consultative activities across Australia, New Zealand and Singapore

The practice of an infectious diseases (ID) physician is evolving. A contemporary understanding of the frequency and variety of patients and syndromes seen by ID services has implications for training, service development and setting research priorities. We performed a 2-week prospective survey of formal ID physician activities related to direct inpatient care, encompassing 53 hospitals throughout Australia, New Zealand and Singapore, and documented 1722 inpatient interactions. Infections involving the skin and soft tissue, respiratory tract and bone/joints together accounted for 49% of all consultations. Suspected/confirmed pathogens were primarily bacterial (60%), rather than viral (6%), fungal (4%), mycobacterial (2%) or parasitic (1%). Staphylococcus aureus was implicated in 409 (24%) episodes, approximately four times more frequently than the next most common pathogen. The frequency of healthcare-related infections (35%), immunosuppression (21%), diabetes mellitus (19%), prosthesis-related infections (13%), multiresistant pathogens (13%) and non-infectious diagnoses (9%) was high, although consultation characteristics varied between geographical settings and hospital types. Our study highlights the diversity of inpatient-related ID activities and should direct future teaching and research. ID physicians’ ability to offer beneficial consultative advice requires broad understanding of, and ability to interact with, a wide range of referring specialities.

Appropriateness of antibiotic prescriptions for hospital emergency department patients

Objective: In Europe, Portugal is considered one of the countries with the highest rates of antimicrobial resistance, an increasing problem worldwide. It is of extreme importance to rationally and appropriately prescribe antibiotics. It has been already described that there is a trend towards antibiotic over-prescription at the emergency department (ED). Thus, we intended to study the antibiotic prescription pattern at the ED of a teaching hospital and its appropriateness. Methods: We retrospectively analyzed all the adults admitted at the ED of a teaching hospital and prescribed with antibiotics during a period of two weeks. Results: From the 7346 ED admissions, we obtained a valid sample of 417 patients, mean age 58.7 ± 22.9 years. There had been previous antibiotic use in 16.8% of these patients and previous hospitalization in 7.9%. General practitioners were responsible for 58.5% of all the antibiotic prescriptions. Among internists' prescriptions, 67.6% were decided by residents. The most diagnosed infections were urinary tract infection (UTI) (17.7%), community acquired pneumonia (CAP) (16.3%) and tonsillitis (11.5%). Antibiotics were prescribed in 6.2% of noninfectious diagnoses. Monotherapy prescriptions accounted for 81.3% of the cases: 41.7% of penicillins and 21.6% of quinolones. For UTI, the most frequently prescribed antibiotics were quinolones (37.5%), sulfonamides (22.2%) and penicillins (20.8%); regarding CAP, quinolones (28.1%) and penicillins (21.9%) were also the preferred options. For tonsillitis, prescribers chose mainly penicillins (76.1%) and macrolides (10.9%). Combined antibiotherapy represented 14.4% of the prescriptions and it was the option in almost half (42.6%) of CAP prescriptions: the most frequent association was penicillin/cephalosporin and macrolide (23.5%). Most patients were discharged; however, 26.6% were admitted to internal medicine wards, 70.3% of them because of lower respiratory tract infections. The antibiotherapy prescribed at the ED was maintained in 80.2% until the discharge. There were 51.3% of appropriate prescriptions: 69.4% for UTI, 58.7% for tonsillitis and 45.3% for CAP. Conclusions: We concluded that almost half of the antibiotic prescriptions at the ED were inappropriate for the established diagnosis, according to the available guidelines. However, ED misdiagnosis was not possible to exclude. In patients admitted to the internal medicine ward, the nondescalation of the large spectrum antibiotherapy prescribed at the ED was an additional example of discordance between daily practices and national recommendations. We also unraveled some of the predictive factors for antibiotic prescription appropriateness. Improving appropriate antibiotic therapy at the emergency department reveals that it is an essential step towards healthcare quality.

Neurocysticercosis: Can we forget it in Europe?

were decided by residents. The most diagnosed infections were urinary tract infection (UTI) (17.7%), community acquired pneumonia (CAP) (16.3%) and tonsillitis (11.5%). Antibiotics were prescribed in 6.2% of noninfectious diagnoses. Monotherapy prescriptions accounted for 81.3% of the cases: 41.7% of penicillins and 21.6% of quinolones. For UTI, the most frequently prescribed antibiotics were quinolones (37.5%), sulfonamides (22.2%) and penicillins (20.8%); regarding CAP, quinolones (28.1%) and penicillins (21.9%) were also the preferred options. For tonsillitis, prescribers chose mainly penicillins (76.1%) and macrolides (10.9%). Combined antibiotherapy represented 14.4% of the prescriptions and it was the option in almost half (42.6%) of CAP prescriptions: the most frequent association was penicillin/ cephalosporin and macrolide (23.5%). Most patients were discharged; however, 26.6% were admitted to internal medicine wards, 70.3% of them because of lower respiratory tract infections. The antibiotherapy prescribed at the EDwasmaintained in 80.2% until the discharge. There were 51.3% of appropriate prescriptions: 69.4% for UTI, 58.7% for tonsillitis and 45.3% for CAP. Conclusions: We concluded that almost half of the antibiotic prescriptions at the ED were inappropriate for the established diagnosis, according to the available guidelines. However, ED misdiagnosis was not possible to exclude. In patients admitted to the internal medicine ward, the nondescalation of the large spectrum antibiotherapy prescribed at the ED was an additional example of discordance between daily practices and national recommendations. We also unraveled some of the predictive factors for antibiotic prescription appropriateness. Improving appropriate antibiotic therapy at the emergency department reveals that it is an essential step towards healthcare quality.

Pulmonary Necrotizing Granulomas of Unknown Cause: Clinical and Pathologic Analysis of 131 Patients With Completely Resected Nodules

The cause of pulmonary necrotizing granulomas is often unclear, even after histologic examination. Our aim was to determine the clinical significance of histologically unexplained necrotizing granulomas. Pulmonary necrotizing granulomas surgically resected at the Mayo Clinic (1994-2004) were retrieved and reviewed retrospectively. Cases in which a cause was evident at the time of initial histologic examination were excluded. The analysis cohort comprised 131 completely resected histologically unexplained pulmonary necrotizing granulomas. Clinical and laboratory information was abstracted from medical records, chest CT scans were reviewed, histologic slides were reexamined, and additional ancillary studies were performed in selected cases. A cause was determined on review in more than one-half of the histologically unexplained necrotizing granulomas (79 of 131, 60%) by reexamining histologic slides (47), incorporating the results of cultures (26), fungal serologies (14), and other laboratory studies (eight), and correlating histologic findings with clinical and radiologic information (13). Infections accounted for the majority (64 of 79), the most common being histoplasmosis (37) and nontuberculous mycobacterial infections (18). Noninfectious diagnoses (15 of 79) were rheumatoid nodule (five), granulomatosis with polyangiitis (Wegener) (five), sarcoidosis (four), and chronic granulomatous disease (one). Many cases remained unexplained even after extensive review (52 of 131, 40%). Most of these patients received no medical therapy and did not progress clinically or develop new nodules (median follow-up, 84 months). A cause, the most common being infection, can be established in many surgically resected pulmonary necrotizing granulomas that appear unexplained at the time of initial histologic diagnosis. Patients whose granulomas remain unexplained after a rigorous review have a favorable outcome. Most do not develop new nodules or progress clinically, even without medical therapy.

Culture Negative Sepsis and Systemic Inflammatory Response Syndrome in Neonates

Sepsis is a common and potentially devastating occurrence in NICUs. Sepsis is defined as the constellation of findings making up the systemic inflammatory response syndrome plus an infection. Newer studies now suggest that treatment of infants who have nonspecific signs of illness with prolonged antibiotics can lead to serious complications. The complexities of practicing medicine in the NICU sometimes limit our ability to secure a diagnosis of culture proven sepsis. The administration of antibiotics until bacterial infection can be reasonably ruled out should occur concurrently with evaluations of other plausible noninfectious diagnoses.

Antibiotic prescription practices for pneumonia, skin and soft tissue infections and urinary tract infections throughout the US Veterans Affairs system

Currently used metrics for antibiotic utilization are not linked to a diagnosis and may be difficult to interpret. We aimed to describe patterns and variation in antibiotic management of three common infectious disease diagnoses in Veterans Affairs Medical Centers (VAMCs). This descriptive retrospective cohort study included all veterans discharged between 2007 and 2009 after an acute care admission to a VAMC and a principal ICD-9-CM code for pneumonia (PNEU), skin and soft-tissue infections (SSTI), urinary tract infections (UTI) or non-infectious disease-related diagnoses (NON_INF). Systemic antibiotic use was assessed based on barcode medication administration data. A treatment period was defined as a time of uninterrupted inpatient antibiotic therapy with no gaps of >1 calendar day. Over the study period there were 1.44 million discharges with an acute care admission to 128 VAMCs included in the study. Of the discharges, 58 118 had a primary ICD-9-CM diagnosis classifiable as PNEU, 36 797 as SSTI, 30 223 as UTI and 1 243 098 as NON_INF. Empirical antibiotic use during the first 2 hospital days was frequent for all infectious disease diagnoses. Type of empirical coverage varied among facilities for all conditions, as did treatment durations. Roughly half of all empirical courses of therapy where the patient was still hospitalized on day 4 did not exhibit any change to the antibiotic regimen. There is substantial variation in the management of common infectious diseases with regard to choice of empirical agents and duration of therapy. Diagnosis-specific antibiotic use metrics may prove useful for antibiotic stewardship programmes.

Characteristics of fever, etiologic factors, antibiotic use and prognosis in febrile dermatology inpatients

Generally, fever is observed in >30% of hospitalized patients. However, little is known about fever in dermatology inpatients. The aim of this study was to investigate and document the incidence, characteristics, and etiologic factors of fever in febrile dermatology inpatients and to describe the practice of antibiotic use and prognosis in the same group. The medical records for 928 inpatients were retrospectively analyzed. The incidence of fever was found to be 16.2%. Mean length of hospital stay was found to be longer in febrile patients. Of the 176 febrile episodes, 79 (44.9%) occurred in patients without infections, 43 (24.4%) in patients with community-acquired infections, 25 (14.2%) in patients with healthcare-associated infections, 18 (10.2%) in patients classified with fever of non-infectious/infectious causes, and 11 (6.3%) in a group for whom the etiologic factors of fever were undetermined. Antibiotic treatment was started in 36.2% of febrile inpatients. The overall mortality rate was 0.6%. This is the first study to investigate febrile episodes in dermatology inpatients. Fever is a frequently encountered symptom in dermatology inpatients. Febrile episodes resulted from mostly non-infectious entities, mainly consisting of inflammatory dermatologic disorders. Antibiotics were ordered in a higher percentage of patients in the febrile group. Dermatologists started prophylactic or empiric antibiotic therapy in febrile patients with non-infectious or inflammatory diagnoses on the assumption that these patients had an increased risk for infection as a result of impaired skin integrity and use of immunosuppressive drug therapy. The overall mortality rate was very low in the study group of dermatology inpatients.

Open-lung biopsy in patients with undiagnosed lung lesions referred at a tertiary cancer center is safe and reveals noncancerous, noninfectious entities as the most common diagnoses

We evaluated the diagnostic yield of open-lung biopsies (OLBs) in a large tertiary cancer center to determine the role of infectious diseases as causes of undiagnosed pulmonary lesions. All consecutive adult patients with either single or multiple pulmonary nodules or masses who underwent a diagnostic OLB over a period of 10 years (1998-2007) were retrospectively identified. Their risk factors for malignancy and clinical and radiological characteristics were reviewed, and their postoperative complications were assessed. We evaluated 155 patients with a median age of 57 years (range, 19-83 years). We identified infectious etiologies in 29 patients (19 %). The most common diagnosis in this group was histoplasmosis (12 [41 %]), followed by nontuberculous mycobacterial infection (7 [24 %]) and aspergillosis (4 [14 %]). The majority of the 126 remaining patients had nonmalignant diagnoses, the most prevalent being nonspecific granuloma (26 %), whereas only 17 % had malignant diagnoses. We observed no significant differences among the patients with infectious, malignant, or both noninfectious and nonmalignant final diagnoses regarding their demographic, laboratory, and clinical characteristics. Six percent of the patients had at least one post-OLB complication, and the post-OLB mortality rate was 1 %. OLB is a safe diagnostic procedure which frequently identifies a wide variety of infectious and inflammatory diseases.

Point‐of‐care Urine Albumin:Creatinine Ratio Is Associated With Outcome in Emergency Department Patients With Sepsis: A Pilot Study

Sepsis is characterized by an initial systemic proinflammatory response leading to endothelial damage and increased capillary permeability. The authors conducted a pilot study to determine if microalbuminuria, measured by the urine albumin:creatinine ratio (ACR), was associated with outcome in emergency department (ED) sepsis patients. This was an observational cohort study of a convenience sample of adult patients presenting to two EDs over 10 months with sepsis (two or more systemic inflammatory response syndrome [SIRS] criteria and suspected infection). Those who received a urinalysis were prospectively enrolled. Patients with anuria, grossly contaminated specimens, or concurrent noninfectious diagnoses were excluded. Urine ACR was measured on a point-of-care (POC) device. The primary study outcome was ED disposition (three groups): treated and discharged, admitted to the floor, or admitted to the intensive care unit (ICU). Kruskal-Wallis testing was used to compare ACR based on disposition. Variables associated with ACR were identified by Spearman rank correlation or Mann-Whitney rank-sum testing. A post hoc subgroup analysis of patients with and without a genitourinary (GU) source of infection was also performed. A total of 121 patients were screened, and 29 (24%) were excluded; 92 patients met criteria (mean ± SD age, 51.2 ± 17.0 years; 51 [55%] had severe sepsis, three [3%] had septic shock). There were three in-hospital deaths. Median ACR for patients treated and discharged (n = 22), admitted to floor (n = 50), and admitted to ICU (n = 20) was 2.54 (interquartile range [IQR] = 0.89 to 6.16) versus 2.8 (IQR = 1.69 to 8.8) versus 12.15 (IQR = 4.76 to 20.95), respectively (p = 0.0049). Age, serum creatinine, and GU source of infection were associated with ACR. ACR was significantly associated with disposition among patients without a GU source of infection (p = 0.003), but not among patients with a GU source (p = 0.3744). In this pilot study, microalbuminuria measured by POC ACR was associated with disposition in ED patients with sepsis or severe sepsis. Larger studies using more robust outcomes comparing ACR with validated sepsis biomarkers are needed to elaborate on these results.

Krankheitslast und Versorgungsniveau bei opioidsubstituierten Patienten

Within the framework of an interdisciplinary cooperation, the authors set up an on-site medical service provider in a specialized methadone substitution center in Germany. Here, they report on the prevalence of infectious and noninfectious diseases, and the vaccination status of substituted heroin-dependent patients. All patients who visited the medical care service provider between February 2008 and December 2008 were included in this study. Ten patients (7%) were seropositive for the hepatitis A virus. Two patients (1.3%) suffered from chronic hepatitis B; 40 patients (27%) were cured after a hepatitis B infection. Additionally, 99 patients (68%) were infected with hepatitis C virus (HCV), and 41 patients (28%) had active hepatitis C. Furthermore, 48 hepatitis C patients (33%) were cured. Of those, 25 patients (17%) cleared the virus spontaneously and 23 (16%) after ribavirin/interferon combination therapy. Ten (7%) of 146 patients were infected with the human immunodeficiency virus (HIV). Of those, four patients had active hepatitis C, and five patients were cured after a hepatitis C infection. 18 patients (12%) were vaccinated against hepatitis A and 28 (19%) against hepatitis B. Two of the 41 patients with chronic hepatitis C were vaccinated against hepatitis A. The most frequent noninfectious diagnoses were arterial hypertension (n = 28), bronchial asthma (n = 8), and diffuse liver parenchymal damage (n = 12). These results emphasize that i.v. drug users on substitution therapy are an underserved collective with a high prevalence of disease. The challenge consists in facilitating this population access to internistic and infectious disease service. The offer of an on-site medical service was well accepted. This is essential for an ongoing reduction of HIV and HCV prevalence in the drug users.

Emergency department utilization by HIV-positive adults in the HAART era

BackgroundNo published study has analyzed emergency department (ED) utilization by human immunodeficiency virus (HIV)-positive adults in the highly active antiretroviral therapy (HAART) era.AimsThe purpose of this study is to describe the demographic and HIV-specific variables associated with ED utilization by HIV-positive adults and their diagnoses when discharged from the ED or subsequently from the hospital.MethodsWe conducted a retrospective cohort study of all HIV-positive adults cared for at a tertiary center HIV clinic and ED (1 January–31 December 2006). Demographic, HIV clinical, and HIV lab variables were abstracted from the clinic database. ED/hospital diagnoses coded by the ICD-9 Diseases/Injuries Tabular Index were abstracted from identified discharge records. We used multivariate logistic regression to compute odds ratios (OR) of ED utilization based on the abstracted variables. We described the cohort and diagnoses using descriptive statistics.ResultsA total of 356 patients met inclusion criteria. Their mean age was 42.7 years, and 77.2% of included patients were male; 52.5% were Caucasian and 47.5% non-Caucasian; 72 patients (20.2%) presented to the ED during the study period [153 visits; 37 (10.4%) required hospitalization (61/153 visits)]. Income level and mean 2006 viral load had a significant association (p < 0.05) with ED utilization. Of 155 ICD-9 ED discharge diagnoses, ill-defined symptoms/signs (25.2%), injury (18.7%), and musculoskeletal disorders (11.6%) were most prevalent. Of 450 ICD-9 hospital discharge diagnoses, endocrine/metabolic (13.3%), psychiatric (12.2%), infectious/parasitic (12%), and circulatory disorders (11.8%) were most prevalent.ConclusionIn this study of HIV-positive adults, income level and mean 2006 viral load had a significant association with ED utilization. Noninfectious diagnoses were alone most prevalent in ED discharged, but not hospitalized, patients.