Nosocomial Risk Research Articles

Proton Pump Inhibitors Use and Risk of Clostridium difficile Infection in Hospitalized Patients

Introduction: Proton pump inhibitors are a common class of medications used to treat gastroesopheageal reflux and acid peptic diseases. Widely used and highly effective,proton pump inhibitors (PPIs) are associated with a number of adverse effects including an increased risk of gastrointestinal infections such as clostridium difficile infection (CDI).In this study we seek to compare the rates of hospital acquired CDI among patients taking PPIs and those not taking PPIs. Methods: After obtaining institutional review board approval, we conducted a retrospective review of all patients admitted to Johnson City Medical Center from January 1, 2013 until May 31, 2014 in order to determine the total number of patients diagnosed with CDI during this time.We classified CDI as present on admission if the diagnosis was made within 72 hours of admission. Clostridium difficile infection diagnosed after 72 hours was classified as hospital acquired.For the purpose of our study we analyzed the cohort of hospital acquired CDI and compared the rate of CDI among PPI users and non-PPI users. We then performed a chart review of the hospital acquired CDI patients to determine the magnitude of risk CDI in PPI users compared to non-PPI users. Categorical data will be compared using Chi square with Yates' correction or Fisher's exact for data entry points less than five. Results: There were a total of 41,663 admissions to Johnson City Medical Center from January 1, 2013 until May 31, 2014. During this time there were 349 diagnoses of CDI, of which 80 were not present on admission. Sixty-five patients who received PPIs in the hospital were diagnosed with nosocomial CDI (0.37%),compared to just 15 patients who did not receive PPI therapy in the hospital (0.06%).This data suggest that PPI use in the hospitalized patient is associated with a 6-fold increase in the risk of nosocomial CDI (P < 0.0001).CDI accounted for nearly $900,000 during the review period, of which $722,737 was spend on CDI in patients taking PPIs. Conclusion: The association between PPI use and risk of CDI is well described, however most studies show that the risk is small with an odds ratio of 2 or less.Our data indicate that the risk of nosocomial CDI in PPI users may be as high as 6 fold compared to non-PPI users. Given the significant morbidity, mortality and cost of treating nosocomial CDI,the indications, risks and benefits of PPI therapy should be carefully weighed and discussed with each patient, particularly in the hospital setting.

Contamination of health care workers' coats at the University Teaching Hospital in Lusaka, Zambia: the nosocomial risk.

BackgroundHealth care Associated Infections (HAIs) are a major public health problem in both developed and developing countries. They pose a severe impact in resource-poor settings, where the rate of infection is estimated to be relatively high. Therefore, this study was conducted to establish empirical evidence related to HAIs in Zambia.MethodThis was a prospective cross-sectional study conducted from October, 2013 to May 2014 at the University Teaching Hospital (UTH) in Lusaka. A total of 107 white coats worn by health care-workers at UTH were sampled for possible bacteriological contamination.ResultsOf the 107 white coats screened, 94 (72.8 %) were contaminated with bacteria. There was no difference in the contamination levels between white coats worn for more than 60 min (47.8 %) compared to those worn for 30–60 min (46.7 %) (p = 0.612). Further, the antibiotic sensitivity tests indicated that the bacterial isolates were resistant to some of the antibiotics assessed. Isolates of Staphylococcus aureus and Klebsiella pnumoniae exhibited the highest resistance to most of the antibiotics assessed.ConclusionThis study has shown that white coats worn by health care-workers at the University Teaching Hospital generally have high microbial contaminations and hence pose a nosocomial risk. It is therefore, recommended that white coats be regularly sanitized, and health care workers also be sensitized on public health risk of HAIs associated with contaminated coats.

Nosocomial infections and risk factors in intensive care unit of a university hospital

Amac: Bu calismada yogun bakim unitesindeki (YBU) hastane enfeksiyonlarinin (HE) enfeksiyon odagi, patojenlerin dagilimi ve risk faktorleri acisindan degerlendirilmesi amaclandi.Yontemler: YBU’de 48 saatten fazla kalan 80 hasta calismaya dahil edildi. Hastalarin epidemiyolojik ozellikleri, invaziv girisimler ve diger risk faktorleri kaydedildi. Kulturler, patojenlerin tanimlanmasi ve antibiyotik duyarlilik testleri standart mikrobiyolojik yontemlerle yapildi.Bulgular: HE gelisen 56 hastanin 26 (%50)’sinda pnomoni, 15 (%28,8)’inde kan dolasimi enfeksiyonu ve 6 (%11.5)’sinda uriner sistem enfeksiyonu saptandi. Klebsiella pneumoniae (%23.5), Pseudomonas aeruginosa (%19,6) ve Acinetobacter spp. (%15,6) sirasiyla en sik saptanan etken mikroorganizmalar idi. Klebsiella pneumoniae izolatlarinda genislemis spektrumlu beta laktamaz (GSBL) orani %91,6, karbapenem direnci %15,6, Pseudomonas aeruginosa ve Acinetobacter spp. izolatlari icin de karbapenem direnci sirasiyla %60 ve %100 olarak saptandi. Hemodiyaliz, enteral beslenme, total parenteral beslenme, 10 gunden uzun sureli yatis HE gelisimi acisindan bagimsiz risk faktorleri olarak saptandi. “Acute Physiology and Chronic Health Evaluation” (APACHE) II skoru, YBU’de yatis suresi ve YBU oncesi hastanede yatis suresi de HE gelisen grupta daha yuksek bulundu.Sonuc: Hastanemiz YBU’de pnomoni en sik gorulen HE olarak saptandi ve Gram-negatif basillerdeki karbapenem direnci dikkat cekici olcude yuksek bulundu. Enfeksiyon kontrol onlemlerinin dikkatli bir sekilde uygulanmasi, invaziv girisimlerin dogru endikasyonlarda uygulanmasi ve gereksiz uzun donem yatislardan kacinilmasi gerektigi dusunuldu

Nosocomial infection investigation and risk factors in neonatal intensive care unit

Objective To study the occurrence of nosocomial infection (NI)situation in the neonatal intensive care unit (NICU)of Xinhua Hospital affiliated to Shanghai Jiaotong University School of Medicine from January 2012 to October 2013, and analyze risk factors of NI. Methods A retrospective study was performed in the NICU, of which all neonates hospitalized over 48 hours were included and the occurrence situation and risk factors of NI were analyzed. Results This study included 1 357 neonates, and 175 neonates developed 202 times NI.The overall incidence of NI was 14.89% (202/1 357), and the incidence density was 10.44 per 1 000 NICU patient-days (202/19 355). The lower the birth weight is, or the smaller gestational age is, the higher the NI rate is.The NI rate was 75.00% in neonates whose birth weight <1 000 g, and the NI rate was 52.63% in neonates whose gestational age <30 weeks.The most common infection type was pneumonia[43.07% (87/202)]and sepsis[26.73% (54/202)]. The hospital stay of the NI neonates was longer and the cost of hospitalization is higher than non-NI neonates (Median stay: 20 days and 10 days.Median cost: 21 045.32 yuan and 8 108.23 yuan)(both P<0.01). Univariate analysis showed there were significant differences between NI neonates and non-NI neonates on gestational age, birth weight, 5 min Apgar score, asphyxia rescue history, previons antibiotics use, mechanical ventilation, peripherelly inserted central catheter(PICC), closed thoracic drainage tube and chest or abdominal surgery before NI.The logistic regression analysis indicated that previous antibiotics use, mechanical ventilation and PICC were important risk factors for NI. Conclusion The NI rate in NICU is still high.Previous antibiotics use, mechanical ventilation and central venous catheter are risk factors of NI. Key words: Neonatal intensive care unit; Neonate; Nosocomial infection; Risk factor

RISK FACTORS AND NOSOCOMIAL INFECTIONS CAUSED BY ENTEROCOCCI

Aim : to analyze nosocomial infections and risk factors caused by enterococci. Review of the foreign and domestic literature on biology and virulence factors of enterococci being the leading causative agents of nosocomial infections is done. Information on risk factors and postoperative infectious complications, pathogens of which are enterococci, in surgical hospitals and hospitals for organ transplantations is provided. The growth of antibiotic resistance in enterococci and the relationship between mortality rate and prevalence rate of antibiotic resistant strains are emphasized

Nosocomial infection and risk factors in elderly patients in intensive care units

65 yas uzerindeki hastalarda nozokomiyal infeksiyon sikligi her gecen gun artmaktadir ve ilerlemis hasta yasi ile nozokomiyal infeksiyon arasinda belirgin bir iliski bulunmaktadir. Bu hastalarda konak savunmasinin azalmasi, altta yatan kronik hastaliklar, hastanede uzun yatis suresi, malnutrisyon, steroid ve immunsupresif kullanimi infeksiyona zemin hazirlayan diger faktorlerdir. Maalesef yasli hastalarda ortaya cikan nozokomiyal infeksiyonlar ve risk faktorleri ile ilgili literaturde cok fazla calisma bulunmamaktadir. Bu calismada yogun bakim unitelerinde yatan yasli hastalarda ortaya cikan nozokomiyal infeksiyonlarin risk faktorlerini ve mortalite uzerine olan etkilerini gostermeyi amacladik.Nozokomiyal infeksiyonlar hastanede kalis suresini uzatan ve mortaliteyi artiran onemli bir etkendir. Mortalite oranlari ve hastaneye yatis ile taburculuk arasinda gecen sure nozokomiyal infeksiyonu olan hastalarda belirgin olarak daha fazladir. Yogun bakim unitelerinde, ileri yas, hastanede uzun yatis suresi, altta yatan hastaliklar, nozokomiyal infeksiyonlar, immunsupresif durumlar, uygulanan invaziv girisimler mortaliteyi artiran bagimsiz risk faktorleridir.Sonuc olarak nozokomiyal infeksiyonlar yogun bakim hastalari icin mortalite uzerinde onemli etkisi olan ve kismen onlenebilir bir risk faktorudur. Uygulanan invaziv islemlerin azaltilmasi bu infeksiyonlardan korunmada onemli bir rol oynamaktadir

Causes of death in people with chronic HBV infection: A population-based cohort study

Mortality related to hepatitis B virus (HBV) is not well known in developed countries. The aim of this study was to investigate in a population-based cohort the excess risk of death in HBV patients compared with mortality in the general population and to identify risk factors related to all-cause mortality and HBV-related mortality. A specialized population-based registry has recorded data from patients with chronic HBV infection in a population of one million inhabitants in France since 1994. Standardized mortality rates for all-cause death and HBV-related death were calculated. Cumulative mortality rates were calculated using the Kaplan-Meier method. Multivariate analysis was performed using a Cox model. Between 1994 and 2009, 1117 people were diagnosed with chronic HBV infection. Of these 136 (12.2%) died. All-cause mortality was significantly higher in HBV-infected people (standardized mortality ratio (SMR) 1.7 [1.4-2.0]). There was substantial excess mortality due to hepatocellular carcinoma (SMR 15.9 [10-24.1]), non-Hodgkin lymphoma (SMR 8.6 [3.1-18.6]) and liver disease (SMR 10.2 [5.8-16.6]). The cumulative rates for all-cause mortality were 8.6% at 5 years, 12.6% at 10 years and 18.5% at 15 years. The corresponding values for HBV-related mortality were 3.5%, 4.2%, and 5.8%. The multivariate analysis for all-cause mortality and for HBV-related mortality showed that male sex, age over 45 at diagnosis, current alcoholism and nosocomial risk factors were predictors of increased mortality. This study shows increased all-cause mortality in HBsAg-positive patients, with considerable excess mortality due to chronic liver disease, hepatocellular carcinoma and non-Hodgkin lymphoma.

Nosocomial Pressure Ulcer Risk Factors in a Relatively Young Adult Population

Background: Pressure ulcers are considered to be a major health problem both in acute and community settings. Numerous studies have explored risk factors related to the development of pressure ulcers but not in a relatively younger population as in Jordan. Aim: The study explores risk factors associated with the development of hospital-acquired pressure ulcers. Design: A cross-sectional multicenter study was conducted. Setting and Sample: All patients matching the study selection criteria were recruited conveniently from three hospitals in Jordan. Statistical Analysis: Descriptive and univariate analysis was performed on the study variables. Multivariate analysis using a special algorithm (‘‘purposeful selection’’) was employed to explore the independent association between a number of risk factors and pressure ulcers. Results: Results from multivariate analysis showed that age, moisture, decreased mobility, presence of three chronic diseases or more, and hypoalbuminemia were independently associated with the development of pressure ulcers when the effect of all other variables in the study was statistically controlled for using logistic regression. Conclusion: This study is the first of its kind that was conducted in Jordan. Results from current work support the findings of previous studies showing that certain risk factors are associated with pressure ulcers. However, the current work also found pressure ulcers to be associated with a younger age (the age cohort above 40 years) than has been reported.

Management of nurse shortage and its impact on pathogen dissemination in the intensive care unit

IntroductionStudies provide evidence that reduced nurse staffing resources are associated to an increase in health care-associated infections in intensive care units, but tools to assess the contribution of the mechanisms driving these relations are still lacking. We present an agent-based model of pathogen spread that can be used to evaluate the impact on nosocomial risk of alternative management decisions adopted to deal with transitory nurse shortage. Materials and methodsWe constructed a model simulating contact-mediated dissemination of pathogens in an intensive-care unit with explicit staffing where nurse availability could be temporarily reduced while maintaining requisites of patient care. We used the model to explore the impact of alternative management decisions adopted to deal with transitory nurse shortage under different pathogen- and institution-specific scenarios. Three alternative strategies could be adopted: increasing the workload of working nurses, hiring substitute nurses, or transferring patients to other intensive-care units. The impact of these decisions on pathogen spread was examined while varying pathogen transmissibility and severity of nurse shortage. ResultsThe model-predicted changes in pathogen prevalence among patients were impacted by management decisions. Simulations showed that increasing nurse workload led to an increase in pathogen spread and that patient transfer could reduce prevalence of pathogens among patients in the intensive-care unit. The outcome of nurse substitution depended on the assumed skills of substitute nurses. Differences between predicted outcomes of each strategy became more evident with increasing transmissibility of the pathogen and with higher rates of nurse shortage. ConclusionsAgent-based models with explicit staff management such as the model presented may prove useful to design staff management policies that mitigate the risk of healthcare-associated infections under episodes of increased nurse shortage.

Clinical analysis of nosocomial infection and risk factors of extremely premature infants

To investigate the incidence of nosocomial infections of extremely premature infants and to explore the risk factors and strategies for infection control. There were 118 extremely premature infants who were confirmed to have nosocomial infection in neonatal intensive care unit of the authors' hospital from January 2008 to December 2012. Their data of the infection rate, risk factors and clinical characteristics were retrospectively analyzed. During the study, nosocomial infection occurred in 78 extremely premature infants 129 times. The nosocomial infection rate was 66.10%. The rate of ventilator-associated pneumonia (VAP) was 1.43% (35/2 452). The catheter related blood stream infection (CRBSI) rate was 0.35% (16/4 613). There were 74 (57.36%) cases of pneumonia, which was the most common nosocomial infection of extremely premature infants. There were 35 cases of VAP, which accounted for 47.30% of pneumonia. The next was sepsis, 48 cases. Seventy-four (74/90, 82.22%) strains of isolates were Gram-negative bacteria, which accounted for the highest proportion, followed by Gram-positive (12 strains), fungus (4 strains); Klebsiella pneumonia is the most common pathogens of nosocomial infection in extremely premature infants. The isolation rates of Klebsiella pneumonia with positive extended-spectrum beta-lactamases (ESBL) were 90.91% (20/22) , universally resistant to cephalosporins. Single-factor analysis showed that the body weight, mechanical ventilation, umbilical vein catheterization, central venous catheter, parenteral nutrition and hospitalization time were risk factors for nosocomial infections in extremely preterm infants. Logistic regression analysis showed that length of hospitalization (OR = 1.024, P = 0.043) and central venous catheterization (OR = 6.170, P = 0.041) were independent risk factors of nosocomial infection. Extremely preterm infants were at higher risk of nosocomial infection. It is important to identify the high risk factors for nosocomial infections in extremely premature infants. To shorten time for mechanical ventilation, central venous catheterization and hospitalization days would be conducive to reducing the morbidity of nosocomial infection.

Nosocomial risk assessment of sterile versus tap water used in “blow bottles” by surgical patients, in a hospital setting

Nosocomial risk assessment of sterile versus tap water used in “blow bottles” by surgical patients, in a hospital setting

Incidence of nosocomial pneumonia and risk of recurrence after antimicrobial therapy in critically ill lung and heart–lung transplant patients

Little is known about the resolution of symptoms of nosocomial pneumonia (NosoP) after lung and heart-lung transplantation. The aim of this study was to describe the clinical response to antimicrobial therapy in (ICU) patients with NosoP after lung or heart-lung transplantation. Between January 2008 and August 2010, 79 lung or heart-lung transplantations patients were prospectively studied. NosoPwas confirmed by quantitative cultures of bronchoalveolar lavage or endotracheal aspirates. Clinical variables, sequential organ failure assessment (SOFA) score, and radiologic score were recorded from start of therapy until day 9. Thirty-five patients (44%) experienced 64 episodes of NosoP in ICU. Fourteen patients (40%) had NosoP recurrence. Most frequently isolated organisms were Enterobacteriaceae (30%), Pseudomonas aeruginosa (25%), and Staphylococcus aureus (20%). Sequential organ failure assessment (SOFA) score improved significantly at day 6 and C-reactive protein level at day 9. SOFA and radiologic scores differed significantly between patients with and without NosoP recurrence at day 3 and 9. The ICU mortality rate did not differ between patients with and without NosoP recurrence, and free of NosoP (14.3%, 9.5%, 11.4%, respectively) (p=0.91). Severities of illness and lung injury were the two major risk factors for NosoP recurrence. Occurrence of NosoP has no impact on ICU mortality.

Six-Year Trend Analysis of Nosocomial Candidemia and Risk factors in Two Intensive Care Hospitals in Mato Grosso, Midwest Region of Brazil

We conducted this cross-sectional retrospective study using clinical and laboratory data from two tertiary hospitals in Cuiabá, Mato Grosso, Brazil, in order to explore the risk factors and estimate mortality, prevalence and lethality of candidemia between 2006 and 2011. A total of 130 episodes of candidemia were identified. The prevalence of candidemia was 1.8 per 1,000 admissions, the mortality rate was 0.9 per 1,000 admissions, and the lethality was 49.2%. The main agent in this population was Candida parapsilosis (n=50), followed by C. albicans (n=45). Comparison between the numbers of episodes in the two triennia revealed that the non-albicans group grew by 48.2%. The distribution of yeast species of Candida per hospital unit revealed that C. albicans was more prevalent than C. parapsilosis in the adult ICU and C. parapsilosis was more prevalent than C. albicans in the neonatal ICU. Patients remained hospitalized for an average of 53.5days. Central venous catheters, parenteral nutrition and age were the variables that proved to be independent in the multivariate analysis and that maintained a statistically significant association with the incidence of death in patients with candidemia. The annual prevalence of candidemia showed a significant increase in the second triennium (2009-2011) compared with the first (2006-2008) probably due to increased exposure to risk factors: central venous catheter, H2 blockers, nutrition parenteral corticosteroids and mean hospital duration.

Tuberculosis in Healthcare Workers and Infection Control Measures at Primary Healthcare Facilities in South Africa

BackgroundChallenges exist regarding TB infection control and TB in hospital-based healthcare workers in South Africa. However, few studies report on TB in non-hospital based healthcare workers such as primary or community healthcare workers. Our objectives were to investigate the implementation of TB infection control measures at primary healthcare facilities, the smear positive TB incidence rate amongst primary healthcare workers and the association between TB infection control measures and all types of TB in healthcare workers.MethodsOne hundred and thirty three primary healthcare facilities were visited in five provinces of South Africa in 2009. At each facility, a TB infection control audit and facility questionnaire were completed. The number of healthcare workers who had had TB during the past three years was obtained.ResultsThe standardised incidence ratio of smear positive TB in primary healthcare workers indicated an incidence rate of more than double that of the general population. In a univariable logistic regression, the infection control audit score was significantly associated with reported cases of TB in healthcare workers (OR=1.04, 95%CI 1.01-1.08, p=0.02) as was the number of staff (OR=3.78, 95%CI 1.77-8.08). In the multivariable analysis, the number of staff remained significantly associated with TB in healthcare workers (OR=3.33, 95%CI 1.37-8.08).ConclusionThe high rate of TB in healthcare workers suggests a substantial nosocomial transmission risk, but the infection control audit tool which was used did not perform adequately as a measure of this risk. Infection control measures should be monitored by validated tools developed and tested locally. Different strategies, such as routine surveillance systems, could be used to evaluate the burden of TB in healthcare workers in order to calculate TB incidence, monitor trends and implement interventions to decrease occupational TB.

Prevalence of the hepatitis B surface antigen in a population of workers in Cameroon

Hepatitis B surface antigen prevalence in populations of blood donors in Cameroon is estimated at 6%-16%. As such, the Objective of this study was to determine the prevalence of Hepatitis B surface antigen in a population of bank employees, who represent a sample closer to the general population. In tests carried out both Yaounde and Douala in December 2011, we detected the hepatitis B surface antigen among 267 workers, including 151 men and 116 women of a median age of 37 years. The Results obtained revealed that the overall prevalence stood at 7.1%, with a 9.9% prevalence ratio in men, three times higher than that in women (3.4%). Subjects aged 20-29 years and senior staffs were more affected (each of them recording 8.1%). Potential nosocomial risks were detected mostly at the level of dental care (52.8%). Among the other risks of exposure, scarification (53.6%) was more frequent. A univariate analysis revealed an insignificant relationship with tattoos (OR 2.6, 95% CI 0.5-10.8, p = 0.2). These results led to the Conclusion that Hepatitis B surface antigen carrier prevalence in a population of workers in Cameroon is not different from that of blood donors. It is mainly due to early vertical and horizontal contamination.

Occupational exposure to body fluids among health care workers in Georgia

Health care workers (HCWs) are at increased risk of being infected with blood-borne pathogens. To evaluate risk of occupational exposure to blood-borne viruses and determine the prevalence of human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV) among HCWs in Georgia. The sample included HCWs from seven medical institutions in five cities in Georgia. A self-administered questionnaire was used to collect information on demographic, occupational and personal risk factors for blood-borne viruses. After obtaining informed consent, blood was drawn from the study participants for a seroprevalence study of HBV, HCV and HIV infections. There were 1386 participating HCWs from a number of departments, including surgery (29%), internal medicine (19%) and intensive care (19%). Nosocomial risk events were reported by the majority of HCWs, including accidental needlestick injury (45%), cuts with contaminated instruments (38%) and blood splashes (46%). The most frequent risk for receiving a cut was related to a false move during a procedure, reassembling devices and handing devices to a colleague. The highest proportion of needlestick injuries among physicians (22%) and nurses (39%) was related to recapping of used needles. No HIV-infected HCW was identified. Prevalence of HCV infection was 5%, anti-HBc was present among 29% with 2% being HBsAg carriers. Data from this study can be utilized in educational programs and implementation of universal safety precautions for HCWs in Georgia to help achieve similar reductions in blood-borne infection transmission to those achieved in developed countries.

Low Rate of Sustained Virological Response in an Outbreak of Acute Hepatitis C in HIV-Infected Patients

Recent reports have suggested an increased risk of acute hepatitis C (AHC) infection in homosexual HIV-infected men and that early treatment with interferon-alfa, alone or associated with ribavirin, significantly reduces the risk of chronic evolution. A retrospective analysis of 38 HIV-infected patients who were consecutively diagnosed as developing AHC, defined by both seroconversion of anti-hepatitis C virus (HCV) antibodies and detection of serum HCV-RNA in those with previous negative results. Thirty-six patients were men with history of unprotected sexual intercourse with men and two were women with sexual and nosocomial risk factors. AHC infection was asymptomatic in 26 patients; asthenia and jaundice were the most frequent symptoms. HCV genotype 1 was present in 19 patients and genotype 4 in 14 patients. Thirty-five patients received early antiviral treatment with pegylated interferon-alfa associated with ribavirin; 15 of the 32 patients who completed the follow-up (47%) achieved a sustained virological response, as defined by undetectable HCV-RNA 6 months after the end of therapy. There is a risk of sexual transmission of HCV in HIV-infected men who have sex with men. In our experience, early treatment of AHC with pegylated interferon-alfa plus ribavirin in HIV patients achieves poor results.

Hepatic Artery Embolization for Neuroendocrine Tumors: Postprocedural Management and Complications

There is scant evidence to guide the management of patients after hepatic artery embolization (HAE). We examined length of stay (LOS), laboratory patterns, medication usage, morbidity, and mortality of patients hospitalized after HAE for metastatic neuroendocrine tumors. Data were abstracted retrospectively from electronic medical records on LOS, liver function tests (LFTs), i.v. antibiotics, analgesia, peak temperature, bacteremia, hepatic abscess formation, carcinoid crisis, and metastatic burden on cross-sectional imaging. In 2005-2009, 72 patients underwent 174 HAEs for carcinoid and islet cell tumors. The median LOS was 4 days (range, 1-8 days). There was no correlation between peak LFTs and tumor burden. Declines in LFTs were not uniform before hospital discharge; 25%, 37%, 30%, 53%, and 67% of patients were discharged before their respective aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, and total and direct bilirubin levels began to decline, with no readmissions for acute hepatic failure. The median i.v. analgesia dose was 60 mg oral morphine equivalents (range, 3-1,961 mg). Pre-HAE i.v. antibiotics were administered in 99% of cases; post-HAE fever occurred in 37% of patients, with no documented bacteremia. One patient developed a hepatic abscess after HAE. There were two carcinoid crises. The single in-hospital death was associated with air in the portal veins. The duration and intensity of in-hospital care following HAE should be managed on an individual basis. A downward trend in LFTs is not required before discharge. Modest use of i.v. analgesia suggests that many patients could exclusively receive oral analgesics. Given the rarity of serious complications, hospital stays could be shortened, thereby reducing costs and nosocomial risks.

Spontan-bakterielle und sekundäre Peritonitis bei Patienten mit Leberzirrhose und Aszites

Peritonitis is one of the most frequent infectious complications in patients with liver cirrhosis and ascites. In more than 95 % it occurs as spontaneous bacterial peritonitis (SBP) as a result of bacterial translocation from intestinal bacteria and bacterial products into mesenteric lymph nodes and subsequent systemic circulation. Identified risk factors that justify antibiotic prophylaxis for SBP include a prior episode of SBP, gastrointestinal haemorrhage and low ascitic fluid protein in combination with renal or advanced liver failure. SBP requires conservative therapy, which should be empirically performed using third-generation cephalosporins and adjunctive albumin therapy under consideration of individual and nosocomial risk factors for antimicrobial resistance. In contrast to SBP, secondary bacterial peritonitis is a rare ( < 5 % of all cases of peritonitis) and more unfavourable disease. It occurs as a result of hollow organ perforation or intra-abdominal inflammatory or ischaemic processes. Analysis of ascitic fluid may help substantiating the suspicion of secondary peritonitis and should entail a meticulous diagnostic work-up including abdominal computed tomography. Because of the high mortality rate (60 - 80 %) of secondary peritonitis antibiotic regimens with anti-anaerobic activity, prompt surgical treatment and interdisciplinary postoperative care are necessary to improve patient outcomes.

Tuberculosis in Antiretroviral Treatment Services in Resource-Limited Settings: Addressing the Challenges of Screening and Diagnosis

The high burden of tuberculosis (TB) among patients accessing antiretroviral treatment (ART) services in resource-limited settings is a major cause of morbidity and mortality and is associated with nosocomial transmission risk. These risks are greatly compounded by multidrug-resistant disease. Screening and diagnosis of TB in this clinical setting is difficult. However, progress has been made in defining a high-sensitivity, standardized symptom screening tool that assesses a combination of symptoms, rather than relying on report of cough alone. Moreover, newly emerging diagnostic tools show great promise in providing more rapid diagnosis of TB, which is predominantly sputum smear–negative. These include culture-based systems, simplified versions of nucleic acid amplification tests (such as the Xpert MTB/RIF assay), and detection of lipoarabinomannan antigen in urine. In addition, new molecular diagnostics now permit rapid detection of drug resistance. Further development and implementation of these tools is vital to permit rapid and effective screening for TB in ART services, which is an essential component of patient care.