University-affiliated Urban Teaching Hospital Research Articles

Follow-up blood cultures in E. coli and Klebsiella spp. bacteremia-opportunities for diagnostic and antimicrobial stewardship.

Uncomplicated Enterobacteriaceae bacteremia is usually transient and may not require follow-up blood cultures (FUBC). This is a retrospective observational study conducted at a university-affiliated urban teaching hospital in Seattle, WA. All patients ≥ 18years hospitalized between July 2014 and August 2019 with ≥ 1 positive blood culture for either Escherichia coli or Klebsiella species were included. The primary outcome was to determine the number and frequency of FUBC obtained, and the detection rate for positive FUBC. There were 335 episodes of E. coli and Klebsiella spp. bacteremia with genitourinary (54%) being the most common source. FUBC were sent in 299 (89.3%) patients, with a median of 3 (interquartile range (IQR): 2, 4) sets of FUBC drawn per patient. Persistent bacteremia occurred in 37 (12.4%) patients. In uncomplicated E. coli and Klebsiella spp. bacteremia, when the pre-test probability of persistent bacteremia is relatively low, FUBC may not be necessary in the absence of predisposing factors.

Improving Rates of Post-Essure Hysterosalpingography in an Urban Population Using Electronic Tracking Reminders

Study ObjectiveTo demonstrate the efficacy of electronic reminders for follow-up hysterosalpingography (HSG) after Essure hysteroscopic sterilization in an urban tertiary care hospital obstetrics and gynecology practice. DesignRetrospective cohort study (Canadian Task Force classification II-3). SettingObstetrics and gynecology practice at a university-affiliated urban tertiary care teaching hospital. PatientsTwo hundred and fifty patients who underwent Essure hysteroscopic sterilization between June 2011 and July 2014. InterventionImplementation of electronic reminders for the office staff. Measurements and Main ResultsTwo hundred and fifty of 259 patients (96.5%) underwent Essure hysteroscopic sterilization and successful placement of coils into bilateral Fallopian tubes. Among these 250 patients, 135 (54%) returned for HSG at 3 months post-Essure as advised at the time of procedure. The use of electronic reminders prompted another 45 patients (18%) to return for HSG, improving the total post-Essure follow-up rate to 72%. ConclusionElectronic reminders for the office staff of an urban tertiary care hospital's obstetrics and gynecology practice is an effective method for improving the rate of post-Essure HSG.

Epidemiology and Microbiology of Sepsis Syndromes in a University-Affiliated Urban Teaching Hospital and Level-1 Trauma and Burn Center.

To use the 2010 to 2011 data collected by structured chart review to provide a detailed up-to-date description of the epidemiology and microbiology of the sepsis syndromes. Prospective observational study conducted at a university-affiliated urban teaching hospital and level-1 trauma and burn center. All adult patients who triggered a Code Sepsis in the emergency department (ED) between January 2010 and December 2011 were included. One hundred eighty four patients presented with a verified sepsis syndrome and triggered a Code Sepsis in the ED during the studied time period. The mean hospital and intensive care unit length of stays (LOSs) were 15.4 (interquartile range [IQR] = 14) and 6.7 (IQR = 5) days, respectively. The total inpatient mortality was 19% (n = 35). Patients with an unspecified source of infection and those without an isolated pathogen had the highest inpatient mortality, 42.1% (n = 8) and 23.3% (n = 10), respectively. Hospital mortality and hospital LOS of sepsis are similar to those reported in other observational studies. Our study confirms a decline in the mortality of sepsis predicted by earlier longitudinal studies and should prompt a resurgence of epidemiological research of the sepsis syndromes in the United States.

Active surveillance cultures of methicillin-resistant Staphylococcus aureus as a tool to predict methicillin-resistant S. aureus ventilator-associated pneumonia*

Ventilator-associated pneumonia is one of the most common infections in the intensive care unit and methicillin-resistant Staphylococcus aureus has emerged as a common cause of ventilator-associated pneumonia. We sought to study the performance characteristics of once weekly active surveillance culture of methicillin-resistant S. aureus colonization in predicting the development of methicillin-resistant S. aureus ventilator-associated pneumonia. Prospective observational study. Eighty-nine-bed surgical and medical intensive care units in a university-affiliated urban teaching hospital and level I trauma and burn center. All patients≥16 yrs old admitted to the intensive care unit on mechanical ventilation≥48 hrs who met diagnostic criteria for ventilator-associated pneumonia by quantitative lower respiratory tract cultures obtained through bronchoscopic alveolar lavage or brush specimen between January 2008 and October 2010 were included. None. Nine hundred twenty-four episodes of suspected ventilator-associated pneumonia were evaluated, and 388 patients with bronchoalveolar lavage-confirmed ventilator-associated pneumonia were included. Surveillance cultures were taken from the nares, oropharynx or trachea, and any open wound routinely on admission to the intensive care unit, every 7 days afterward, and at intensive care unit discharge. Of the 388 patients, 37 (9.5%) had methicillin-resistant S. aureus ventilator-associated pneumonia and 54 (13.9%) had methicillin-resistant S. aureus colonization documented by active surveillance culture before the development of ventilator-associated pneumonia. The sensitivity and specificity of prior methicillin-resistant S. aureus colonization as a predictor for methicillin-resistant S. aureus ventilator-associated pneumonia are 70.3% (95% confidence interval [CI] 52.8-83.6) and 92.0% (95% CI 88.5-94.5), respectively. The positive and negative predictive values are 48.1% (95% CI 34.5- 62.0) and 96.7% (95% CI 94.0-98.3). In our study, prior methicillin-resistant S. aureus colonization as ascertained by once-weekly active surveillance culture yielded high specificity and negative predictive value, suggesting that negative active surveillance culture can accurately exclude methicillin-resistant S. aureus as an etiology in most patients with ventilator-associated pneumonia and may decrease the need for empirical methicillin-resistant S. aureus coverage in patients with suspected ventilator-associated pneumonia.

The challenge of providing infertility services to a low-income immigrant Latino population

To provide insight into the experience of low-income immigrant Latino couples seeking infertility treatment. Qualitative interview study. Infertility clinic at a university-affiliated urban public teaching hospital. Infertile low-income immigrant Latino couples (105 women and 40 men). In-depth, tape-recorded interviews. After transcription and translation, the interviews were coded and analyzed for thematic content. Four major challenges to providing infertility services to this population were identified: [1] communication: language and cultural barriers resulted in patients having difficulty both in understanding diagnoses and treatments and in communicating their questions, concerns, and experiences to physicians; [2] continuity: because medical students and residents rotated frequently, patients usually saw a different physician at each visit; [3] bureaucracy: patients reported having difficulty with appointment scheduling, follow-up visits, and timed laboratory procedures; and [4] accessibility: patients faced issues of limited availability and affordability of treatment. At a large, urban, university-affiliated infertility clinic, challenges related to communication, comprehension, continuity, bureaucracy, accessibility, availability, and affordability impeded the delivery of optimal infertility care to many low-income immigrant Latino patients. A greater availability of translators and both patient and physician cultural orientations to address these health care barriers is recommended.

Antibiotic Utilization and Outcomes for Patients With Clinically Suspected Ventilator-Associated Pneumonia and Negative Quantitative BAL Culture Results

To evaluate antibiotic utilization and clinical outcomes among patients with clinically suspected ventilator-associated pneumonia (VAP) and culture-negative BAL (CNBAL). Prospective observational cohort study. A medical ICU from a university-affiliated urban teaching hospital employing a previously described antibiotic discontinuation guideline for the management of VAP. One hundred one patients with a clinical suspicion of VAP and CNBAL were evaluated between July 2002 and December 2004. Prospective patient follow-up and data collection. Antibiotic discontinuation was determined by the clinical guideline and not the results of BAL cultures. The average age of the patients was 60.4 +/- 17.9 years and the mean APACHE II score was 23.2 +/- 8.7 (+/- SD). The mean duration of mechanical ventilation prior to clinically suspected VAP was 2.9 +/- 1.9 days. Nineteen patients (18.8%) received antibiotics for other indications prior to BAL. Empiric antibiotic therapy for VAP was begun in 65 patients (64.4%) following BAL. The duration of empiric antibiotic treatment following BAL was 2.1 +/- 0.8 days. None of these patients received antibiotics for > 3 days (median, 2 days; range, 1 to 3 days). Six patients (5.9%) were treated with antibiotics for a secondary episode of VAP or hospital-acquired pneumonia developing at least 72 h after the CNBAL was performed and discontinuation of the empiric antibiotic therapy prescribed for the initially suspected episode of VAP. Overall, 35 patients (34.7%) died during hospitalization. Two deaths occurred in patients with a secondary episode of VAP following CNBAL and discontinuation of empiric antimicrobial therapy. Neither of these two deaths was attributed to VAP. Although the decision to discontinue antibiotic treatment was based on clinical criteria and not BAL culture results, this study suggests that patients with a clinical suspicion of VAP and CNBAL can have empiric antimicrobial therapy safely discontinued within 72 h or in some cases withheld altogether. Prospective studies are needed to determine the safety of employing CNBAL as the primary criterion for the discontinuation of empirically begun antibiotic treatment for VAP.

A strategy to improve the detection of drug-induced hepatotoxicity

To report a new strategy for the detection of hepatotoxic adverse drug reactions (ADRs) in hospitalized patients improving the results obtained with other methods. The model is based on the identification of a single alert signal in various target clinical departments over a 12-month period. Each patient was later interviewed following a set protocol. The main results analyzed were the drugs suspected of ADR; causal relationship between suspected drugs and ADRs; ADR severity, and incidence of hepatotoxic ADR/100,000 inhabitants. Population served by a university-affiliated urban teaching hospital (519,381 inhabitants). The overall ratio of confirmed/suspected ADRs was high (35/80). The most commonly reported drug was amoxicillin-clavulanic acid (4 cases). With regard to causality, 2 suspected cases were classified as definite and 14 as probable. The distribution according to the severity of hepatotoxicity was 6 severe and 29 mild cases. The incidence of hepatotoxic ADRs/100,000 inhabitants as revealed by our method was much higher versus voluntary report (6.74 and 1.79, respectively). Our method has proven effective for improving the detection of hepatotoxic ADRs, and may be extended to other types of adverse reactions.

A Randomized Controlled Trial of an Antibiotic Discontinuation Policy for Clinically Suspected Ventilator-Associated Pneumonia

To evaluate an antibiotic discontinuation policy for clinically suspected ventilator-associated pneumonia (VAP). Prospective, randomized, controlled clinical trial. A medical ICU from a university-affiliated urban teaching hospital. Between April 2002 and July 2003, 290 patients completed the clinical trial. Patients were assigned to have the duration of antibiotic treatment for VAP determined by an antibiotic discontinuation policy (discontinuation group) or their treating physician teams (conventional group). Severity of illness using APACHE (acute physiology and chronic health evaluation) II score (22.8 +/- 9.0 vs 23.2 +/- 9.4, p = 0.683) [mean +/- SD] and the clinical pulmonary infection score (7.1 +/- 0.9 vs 7.2 +/- 0.9, p = 0.222) were similar for both patient groups. The duration of antibiotic treatment for VAP was statistically shorter among patients in the discontinuation group compared to patients in the conventional antibiotic management group (6.0 +/- 4.9 days vs 8.0 +/- 5.6 days, p = 0.001). The occurrence of a secondary episode of VAP was not statistically different between these two groups (17.3% vs 19.3%, p = 0.667). Hospital mortality (32.0% vs 37.1%, p = 0.357) and ICU length of stay (6.8 +/- 6.1 days vs 7.0 +/- 7.3 days, p = 0.798) were also statistically similar. The application of an antibiotic discontinuation policy for clinically suspected VAP was associated with a decrease in the overall duration of antibiotic treatment. These findings suggest that shorter courses of empiric antibiotic therapy for patients treated for clinically suspected VAP can be safely achieved.

Dacron femoral-popliteal bypass grafts in good-risk claudicant patients

Purpose To evaluate prosthetic femoral-popliteal (FP) grafts as bypass conduits in favorable patients with refractory calf claudication. Setting University-affiliated urban teaching hospital. Methods Cohort study of patency of 6-mm Dacron FP grafts used to treat patients with medically refractory calf claudication meeting the following criteria: nonsmoker; above-knee popliteal artery as an appropriate target vessel; ≥2-vessel tibial outflow; and postoperative anticoagulation and antiplatelet therapy. End points included primary and secondary FP graft patency, need for and outcome of subsequent intervention, limb amputation, and survival. Results From January 1998 through March 2001, 92 patients underwent 100 Dacron bypass grafts for medically refractory claudication. All underwent serial postoperative graft surveillance using duplex ultrasound. Using the Society for Vascular Surgery/International Society of Cardiovascular Surgery criteria life-table, primary patency was 84%, assisted primary patency was 88%, and secondary patency was 90% at 5 years. Two patients (2%) died during a mean follow-up period of 49 months (range 30 to 68). No limbs required amputation. Among 9 limbs in which Dacron FP bypass failed, 8 underwent subsequent successful autogenous bypass to the popliteal artery. Conclusion In highly selected subjects with favorable features known to increase the likelihood of prosthetic graft patency, prosthetic FP grafts function well. Such patients undergo a simpler, more straightforward procedure than when autogenous FP bypass is performed. Subsequent success of autogenous FP repeat bypass suggests that previous prosthetic FP bypass does not threaten lower-extremity arterial outflow.

Hospital Mortality for Patients With Bacteremia Due to Staphylococcus aureus or Pseudomonas aeruginosa

To evaluate the relationship between hospital mortality and bloodstream infections due to Staphylococcus aureus or Pseudomonas aeruginosa. Prospective cohort study. A 1,400-bed, university-affiliated urban teaching hospital. Between December 2001 and September 2002, 314 patients with bacteremia due to S aureus or P aeruginosa were prospectively evaluated. Prospective patient surveillance and data collection. Thirteen patients (4.1%) received inadequate initial antibiotic treatment. Fifty-four patients (17.2%) died during hospitalization. Hospital mortality was statistically greater for patients with bloodstream infections due to P aeruginosa (n = 49) compared to methicillin-sensitive S aureus (MSSA) [n = 117; 30.6% vs 16.2%, p = 0.036] and methicillin-resistant S aureus (MRSA) [n = 148; 30.6% vs 13.5%, p = 0.007]. Multiple logistic regression analysis identified the lack of response to initial medical treatment (adjusted odds ratio [AOR], 2.69; 95% confidence interval [CI], 1.83 to 3.94; p = 0.010) and endocarditis (AOR, 4.62; 95% CI, 2.45 to 8.73; p = 0.016) as independent determinants of hospital mortality. Patients with bloodstream infections due to P aeruginosa were statistically more likely to be nonresponders to early medical treatment compared to patients with MSSA (73.5% vs 11.1%, p < 0.001) and MRSA (73.5% vs 16.9%, p < 0.001) bloodstream infections. These data suggest that bloodstream infections due to P aeruginosa have a greater risk of hospital mortality compared to bloodstream infections due to S aureus despite adequate antibiotic treatment.

Hospital-Acquired Pneumonia : Risk Factors for Antimicrobial-Resistant Causative Pathogens in Critically Ill Patients

To determine factors associated with antimicrobial-resistant hospital-acquired pneumonia (AR-HAP), to build an algorithm evaluating the risk for such a pneumonia, and to test this algorithm. Combined observational and validation cohorts over two periods: January 1994 to December 1999, and January 2000 to March 2001. One ICU from a university-affiliated urban teaching hospital. One hundred twenty-four patients in the observational cohort and 26 patients in the validation cohort exhibiting bacteriologically documented hospital-acquired pneumonia (HAP). Prospective data collection and multivariate analysis using the chi(2) automatic interaction and detection technique. In the observational cohort, 39 antimicrobial-resistant bacteria were incriminated in 37 patients (30%). Multivariate analysis identified four independent variables allowing a binary stratification of risk. According to the presence or absence of prior antimicrobial treatment, neurologic disturbances on ICU admission, aspiration on ICU admission, and time elapsed between ICU admission and the onset of pneumonia, we were able to identify and separate patients at high, low, or even no risk for acquiring AR-HAP. In the validation cohort, nine antimicrobial-resistant bacteria were incriminated in nine patients (34.6%). In this cohort, the algorithm performed well allowing the identification of null risk categories: the absence of prior antimicrobial treatment, the presence of prior antimicrobial treatment with neurologic disturbances on ICU admission and an early-onset pneumonia, and the presence of prior antimicrobial treatment without neurologic disturbances but with aspiration on ICU admission were always associated with antimicrobial-susceptible HAP. We developed and tested a binary algorithm allowing the identification of patients at low risk for acquiring AR-HAP. An antibiotic strategy including an initial antimicrobial treatment guided by such an algorithm, followed, if possible, by a de-escalation when antimicrobial data are available, could increase the administration of adequate initial antimicrobial treatment and help prevent the emergence of antibiotic resistance in the ICU.

Clinical Utility of Blood Cultures Drawn From Central Vein Catheters and Peripheral Venipuncture in Critically Ill Medical Patients

To determine the sensitivity, specificity, and positive and negative predictive values of blood cultures obtained through a central vein catheter compared with peripheral venipuncture. Prospective cohort study. A medical ICU (19 beds) from a university-affiliated urban teaching hospital. Between February 2001 and October 2001, 300 paired blood culture specimens were obtained from 119 patients (2.52 paired cultures per patient). Prospective patient surveillance and data collection. Thirty-four paired culture results (11.3%; 95% confidence interval, 7.8 to 14.8%) were accepted as true-positives representing a true bacteremia. The sensitivity of catheter-drawn and peripheral venipuncture samples was 82.4% and 64.7%, respectively, and specificity was 92.5% and 95.9%. The positive predictive value was 58.3% for catheter-drawn samples and 66.7% for peripheral venipuncture samples, and the respective negative predictive values were 97.6% and 95.5%. In critically ill medical patients, the negative predictive value of blood samples obtained by catheter draw or peripheral venipuncture for suspected bloodstream infection is good. However, the sensitivity of blood samples obtained by either catheter draw or peripheral venipuncture alone is not adequate to recommend the elimination of blood samples obtained from the other site. Clinicians should also be aware that additional blood samples may be necessary when interpreting positive blood culture results for common skin or central vein catheter contaminants.

Fever in a medical intensive care unit

Objective: To determine the epidemiology of fever in a medical intensive care unit (ICU). Design: Period prevalence study. Setting: Medical ICU of a university-affiliated urban teaching hospital. Subjects: Sixty-eight consecutive patients with a medical admission diagnosis over a 2-month period in 2002. Interventions: None. Measurements and main results: Forty-eight patients (71%) experienced fever during their ICU stay that was of infectious origin in only 62% of the cases. Prolonged and high-grade fevers were usually due to infections. During the first 96 hours, infected patients had significant higher daily procalcitonin level compared with non-infected patients, whereas there was no difference in leukocyte count between the two groups. C-reactive protein levels were significantly different only at day 4. Conclusions: In medical ICU patients, fever is frequently seen and commonly due to non-infectious causes. Body temperature is an easily measurable parameter with a high level of sensitivity (97%) but ...

Fever in a medical intensive care unit

Objective: To determine the epidemiology of fever in a medical intensive care unit (ICU). Design: Period prevalence study. Setting: Medical ICU of a university-affiliated urban teaching hospital. Subjects: Sixty-eight consecutive patients with a medical admission diagnosis over a 2-month period in 2002. Interventions: None. Measurements and main results: Forty-eight patients (71%) experienced fever during their ICU stay that was of infectious origin in only 62% of the cases. Prolonged and high-grade fevers were usually due to infections. During the first 96 hours, infected patients had significant higher daily procalcitonin level compared with non-infected patients, whereas there was no difference in leukocyte count between the two groups. C-reactive protein levels were significantly different only at day 4. Conclusions: In medical ICU patients, fever is frequently seen and commonly due to non-infectious causes. Body temperature is an easily measurable parameter with a high level of sensitivity (97%) but poor specificity (51%) for infection in these patients.

Clinical Importance of Delays in the Initiation of Appropriate Antibiotic Treatment for Ventilator-Associated Pneumonia

To determine the influence of initially delayed appropriate antibiotic treatment (IDAAT) on the outcomes of patients with ventilator-associated pneumonia (VAP). Medical ICU of Barnes-Jewish Hospital, St. Louis, a university-affiliated urban teaching hospital. One hundred seven consecutive patients receiving mechanical ventilation and antibiotic treatment for VAP. Prospective patient surveillance and data collection. All 107 patients eventually received treatment with an antibiotic regimen that was shown in vitro to be active against the bacterial pathogens isolated from their respiratory secretions. Thirty-three patients (30.8%) received antibiotic treatment that was delayed for >or= 24 h after initially meeting diagnostic criteria for VAP. These patients were classified as receiving IDAAT. The most common reason for the administration of IDAAT was a delay in writing the antibiotic orders (n = 25; 75.8%). The mean time (+/- SD) interval from initially meeting the diagnostic criteria for VAP until the administration of antibiotic treatment was 28.6 +/- 5.8 h among patients classified as receiving IDAAT, compared to 12.5 +/- 4.2 h for all other patients (p < 0.001). Forty-four patients (41.1%) with VAP died during their hospitalization. Increasing APACHE (acute physiology and chronic health evaluation) II scores (adjusted odds ratio, 1.13; 95% confidence interval, 1.09 to 1.18; p < 0.001), presence of malignancy (adjusted odds ratio, 3.20; 95% confidence interval, 1.79 to 5.71; p = 0.044), and the administration of IDAAT (adjusted odds ratio, 7.68; 95% confidence interval, 4.50 to 13.09; p < 0.001) were identified as risk factors independently associated with hospital mortality by logistic regression analysis. These data suggest that patients classified as receiving IDAAT are at greater risk for hospital mortality. Clinicians should avoid delaying the administration of appropriate antibiotic treatment to patients with VAP in order to minimize their risk of mortality.

The Influence of Inadequate Antimicrobial Treatment of Bloodstream Infections on Patient Outcomes in the ICU Setting

To evaluate the relationship between the adequacy of antimicrobial treatment for bloodstream infections and clinical outcomes among patients requiring ICU admission. Prospective cohort study. A medical ICU (19 beds) and a surgical ICU (18 beds) from a university-affiliated urban teaching hospital. Between July 1997 and July 1999, 492 patients were prospectively evaluated. Prospective patient surveillance and data collection. One hundred forty-seven patients (29.9%) received inadequate antimicrobial treatment for their bloodstream infections. The hospital mortality rate of patients with a bloodstream infection receiving inadequate antimicrobial treatment (61.9%) was statistically greater than the hospital mortality rate of patients with a bloodstream infection who received adequate antimicrobial treatment (28.4%; relative risk, 2. 18; 95% confidence interval [CI], 1.77 to 2.69; p < 0.001). Multiple logistic regression analysis identified the administration of inadequate antimicrobial treatment as an independent determinant of hospital mortality (adjusted odds ratio [AOR], 6.86; 95% CI, 5.09 to 9.24; p < 0.001). The most commonly identified bloodstream pathogens and their associated rates of inadequate antimicrobial treatment included vancomycin-resistant enterococci (n = 17; 100%), Candida species (n = 41; 95.1%), oxacillin-resistant Staphylococcus aureus (n = 46; 32.6%), coagulase-negative staphylococci (n = 96; 21.9%), and Pseudomonas aeruginosa (n = 22; 10.0%). A statistically significant relationship was found between the rates of inadequate antimicrobial treatment for individual microorganisms and their associated rates of hospital mortality (Spearman correlation coefficient = 0.8287; p = 0.006). Multiple logistic regression analysis also demonstrated that a bloodstream infection attributed to Candida species (AOR, 51.86; 95% CI, 24.57 to 109.49; p < 0.001), prior administration of antibiotics during the same hospitalization (AOR, 2.08; 95% CI, 1.58 to 2.74; p = 0.008), decreasing serum albumin concentrations (1-g/dL decrements) (AOR, 1.37; 95% CI, 1.21 to 1.56; p = 0.014), and increasing central catheter duration (1-day increments) (AOR, 1.03; 95% CI, 1.02 to 1.04; p = 0.008) were independently associated with the administration of inadequate antimicrobial treatment. The administration of inadequate antimicrobial treatment to critically ill patients with bloodstream infections is associated with a greater hospital mortality compared with adequate antimicrobial treatment of bloodstream infections. These data suggest that clinical efforts should be aimed at reducing the administration of inadequate antimicrobial treatment to hospitalized patients with bloodstream infections, especially individuals infected with antibiotic-resistant bacteria and Candida species.

A Comparative Analysis of Patients With Early-Onset vs Late-Onset Nosocomial Pneumonia in the ICU Setting

To compare the clinical outcomes of critically ill patients developing early-onset nosocomial pneumonia (NP; ie, within 96 h of ICU admission) and late-onset NP (ie, occurring after 96 h of ICU admission). Prospective cohort study. A medical ICU and a surgical ICU from a university-affiliated urban teaching hospital. Between July 1997 and November 1998, 3, 668 patients were prospectively evaluated. Prospective patient surveillance and data collection. Four hundred twenty patients (11.5%) developed NP. Early-onset NP was observed in 235 patients (56.0%), whereas 185 patients (44.0%) developed late-onset NP. Among patients with early onset NP, 114 patients (48. 5%) spent at least 24 h in the hospital prior to ICU admission, compared to 57 patients (30.8%) with late-onset NP (p = 0.001). One hundred eighty-three patients (77.9%) with early-onset NP received antibiotics prior to the development of NP, as compared to 162 patients (87.6%) with late-onset NP (p = 0.010). The most common pathogens associated with early-onset NP were Pseudomonas aeruginosa (25.1%), oxacillin-sensitive Staphylococcus aureus (OSSA; 17.9%), oxacillin-resistant S aureus (ORSA; 17.9%), and Enterobacter species (10.2%). P aeruginosa (38.4%), ORSA (21.1%), Stenotrophomonas maltophilia (11.4%), OSSA (10.8%), and Enterobacter species (10.3%) were the most common pathogens associated with late-onset NP. The ICU length of stay was significantly longer for patients with early-onset NP (10.3 +/- 8.3 days; p < 0.001) and late-onset NP (21. 0 +/- 13.7 days; p < 0.001), as compared to patients without NP (3.5 +/- 3.2 days). Hospital mortality was significantly greater for patients with early-onset NP (37.9%; p = 0.001) and late-onset NP (41.1%; p = 0.001) compared to patients without NP (13.1%). Both early-onset and late-onset NP are associated with increased hospital mortality rates and prolonged lengths of stay. The pathogens associated with NP were similar for both groups. This may be due, in part, to the prior hospitalization and use of antibiotics in many patients developing early-onset NP. These data suggest that P aeruginosa and ORSA can be important pathogens associated with early-onset NP in the ICU setting. Additionally, clinicians should be aware of the common microorganisms associated with both early-onset NP and late-onset NP in their hospitals in order to avoid the administration of inadequate antimicrobial treatment.

Inadequate Antimicrobial Treatment of Infections: A Risk Factor for Hospital Mortality Among Critically Ill Patients

To evaluate the relationship between inadequate antimicrobial treatment of infections (both community-acquired and nosocomial infections) and hospital mortality for patients requiring ICU admission. Prospective cohort study. Barnes-Jewish Hospital, a university-affiliated urban teaching hospital. Two thousand consecutive patients requiring admission to the medical or surgical ICU. Prospective patient surveillance and data collection. One hundred sixty-nine (8.5%) infected patients received inadequate antimicrobial treatment of their infections. This represented 25.8% of the 655 patients assessed to have either community-acquired or nosocomial infections. The occurrence of inadequate antimicrobial treatment of infection was most common among patients with nosocomial infections, which developed after treatment of a community-acquired infection (45.2%), followed by patients with nosocomial infections alone (34.3%) and patients with community-acquired infections alone (17.1%) (p < 0.001). Multiple logistic regression analysis, using only the cohort of infected patients (n = 655), demonstrated that the prior administration of antibiotics (adjusted odds ratio [OR], 3.39; 95% confidence interval [CI], 2.88 to 4.23; p < 0.001), presence of a bloodstream infection (adjusted OR, 1.88; 95% CI, 1.52 to 2.32; p = 0.003), increasing acute physiology and chronic health evaluation (APACHE) II scores (adjusted OR, 1.04; 95% CI, 1.03 to 1.05; p = 0.002), and decreasing patient age (adjusted OR, 1.01; 95% CI, 1.01 to 1.02; p = 0.012) were independently associated with the administration of inadequate antimicrobial treatment. The hospital mortality rate of infected patients receiving inadequate antimicrobial treatment (52.1%) was statistically greater than the hospital mortality rate of the remaining patients in the cohort (n = 1,831) without this risk factor (12.2%) (relative risk [RR], 4.26; 95% CI, 3.52 to 5.15; p < 0.001). Similarly, the infection-related mortality rate for infected patients receiving inadequate antimicrobial treatment (42.0%) was significantly greater than the infection-related mortality rate of infected patients receiving adequate antimicrobial treatment (17.7%) (RR, 2.37; 95% CI, 1.83 to 3.08; p < 0.001). Using a logistic regression model, inadequate antimicrobial treatment of infection was found to be the most important independent determinant of hospital mortality for the entire patient cohort (adjusted OR, 4.27; 95% CI, 3.35 to 5.44; p < 0.001). The other identified independent determinants of hospital mortality included the number of acquired organ system derangements, use of vasopressor agents, the presence of an underlying malignancy, increasing APACHE II scores, increasing age, and having a nonsurgical diagnosis at the time of ICU admission. Inadequate treatment of infections among patients requiring ICU admission appears to be an important determinant of hospital mortality. These data suggest that clinical efforts aimed at reducing the occurrence of inadequate antimicrobial treatment could improve the outcomes of critically ill patients. Additionally, prior antimicrobial therapy should be recognized as an important risk factor for the administration of inadequate antimicrobial treatment among ICU patients with clinically suspected infections.

Information contents of drug advertisements: an Indian experience.

To critically analyze the drug information contained in Indian pharmaceutical advertisements. Analysis of pharmaceutical advertisements supplied by drug representatives (DRs) to prescribers from July 1, 1995, to June 30, 1996. A university-affiliated urban teaching hospital in India. 585 pharmaceutical ad pamphlets. The ads supplied by DRs to physicians in different clinical departments of the hospital were collected. These were distributed to different systems/categories and a special reference to fixed-dose drug combinations was given. The drug information contained in these ads was evaluated by using a checklist, framed by incorporating the World Health Organization ethical guidelines for medicinal drug promotion and some relevant items from other studies. The most frequently occurring ads were for antimicrobial agents. The ads on fixed-dose drug combinations constituted 37.9% of the total. More than 85% of the ads mentioned the generic name, brand name, contents, and pharmaceutical dosage forms, as well as the name and address of the company. The information concerning adverse effects, precautions, contraindications, warnings, major interactions, ingredients known to cause problems, pharmacology, drug overdose, references, drug storage, and cost was present in less than 40% of these ads. There has been inadequate information in pharmaceutical ads supplied by DRs to the physicians in India. The current scenario could be improved by formulating some definite legislative guidelines for the minimum level of information to be included in pharmaceutical ads and adhering to that legislation.

The Use of Continuous IV Sedation Is Associated With Prolongation of Mechanical Ventilation

To determine whether the use of continuous i.v. sedation is associated with prolongation of the duration of mechanical ventilation. Prospective observational cohort study. The medical ICU of Barnes-Jewish Hospital, a university-affiliated urban teaching hospital. Two hundred forty-two consecutive ICU patients requiring mechanical ventilation. Patient surveillance and data collection. The primary outcome measure was the duration of mechanical ventilation. Secondary outcome measures included ICU and hospital lengths of stay, hospital mortality, and acquired organ system derangements. A total of 93 (38.4%) mechanically ventilated patients received continuous i.v. sedation while 149 (61.6%) patients received either bolus administration of i.v. sedation (n=64) or no i.v. sedation (n=85) following intubation. The duration of mechanical ventilation was significantly longer for patients receiving continuous i.v. sedation compared with patients not receiving continuous i.v. sedation (185+/-190 h vs 55.6+/-75.6 h; p<0.001). Similarly, the lengths of intensive care (13.5+/-33.7 days vs 4.8+/-4.1 days; p<0.001) and hospitalization (21.0+/-25.1 days vs 12.8+/-14.1 days; p<0.001) were statistically longer among patients receiving continuous i.v. sedation. Multiple linear regression analysis, adjusting for age, gender, severity of illness, mortality, indication for mechanical ventilation, use of chemical paralysis, presence of a tracheostomy, and the number of acquired organ system derangements, found the adjusted duration of mechanical ventilation to be significantly longer for patients receiving continuous i.v. sedation compared with patients who did not receive continuous i.v. sedation (148 h [95% confidence interval: 121, 175 h] vs 78.7 h [95% confidence interval: 68.9, 88.6 h]; p<0.001). We conclude from these preliminary observational data that the use of continuous i.v. sedation may be associated with the prolongation of mechanical ventilation. This study suggests that strategies targeted at reducing the use of continuous i.v. sedation could shorten the duration of mechanical ventilation for some patients. Prospective randomized clinical trials, using well-designed sedation guidelines and protocols, are required to determine whether patient-specific outcomes (eg, duration of mechanical ventilation, patient comfort) can be improved compared with conventional sedation practices.