Society for Healthcare Epidemiology of America and Infectious Diseases Society of America Joint Committee on the Prevention of Antimicrobial Resistance: guidelines for the prevention of antimicrobial resistance in hospitals

Modeling the effects of introducing a new antibiotic in a hospital setting: A case study

The increase in antibiotic resistance continues to pose a public health risk as very few new antibiotics are being produced, and bacteria resistant to currently prescribed antibiotics is growing. Within a typical hospital setting, one may find patients colonized with bacteria resistant to a single antibiotic, or, of a more emergent threat, patients may be colonized with bacteria resistant to multiple antibiotics. Precautions have been implemented to try to prevent the growth and spread of antimicrobial resistance such as a reduction in the distribution of antibiotics and increased hand washing and barrier preventions; however, the rise of this resistance is still evident. As a result, there is a new movement to try to re-examine the need for the development of new antibiotics. In this paper, we use mathematical models to study the possible benefits of implementing a new antibiotic in this setting; through these models, we examine the use of a new antibiotic that is distributed in various ways and how this could reduce total resistance in the hospital. We compare several different models in which patients colonized with both single and dual-resistant bacteria are present, including a model with no additional treatment protocols for the population colonized with dual-resistant bacteria as well as models including isolation and/or treatment with a new antibiotic. We examine the benefits and limitations of each scenario in the simulations presented.

Policy statement on antimicrobial stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS)

Antimicrobial resistance has emerged as a significant healthcare quality and patient safety issue in the twenty-first century that, combined with a rapidly dwindling antimicrobial armamentarium, has resulted in a critical threat to the public health of the United States. Antimicrobial stewardship programs optimize antimicrobial use to achieve the best clinical outcomes while minimizing adverse events and limiting selective pressures that drive the emergence of resistance and may also reduce excessive costs attributable to suboptimal antimicrobial use. Therefore, antimicrobial stewardship must be a fiduciary responsibility for all healthcare institutions across the continuum of care. This position statement of the Society for Healthcare Epidemiology of America, the Infectious Diseases Society of America, and the Pediatric Infectious Diseases Society of America outlines recommendations for the mandatory implementation of antimicrobial stewardship throughout health care, suggests process and outcome measures to monitor these interventions, and addresses deficiencies in education and research in this field as well as the lack of accurate data on antimicrobial use in the United States.

Neonatology in the emerging countries: the strategies and health-economics challenges related to prevention of neonatal and infant infections

The prevalence of neonatal and infant infections is higher in emerging countries when compared to the developed world. Major factors associated to this increased frequency include the scarcity of trained health personnel, overcrowding of the neonatal units, late onset and slow advance of feeding, use of formula instead of breastfeeding, failure to comply with handwashing recommendations, and excessive use of antibiotics, resulting in the emergence of resistant strains. Infants discharged home frequently share rooms with a large number of siblings and other cohabitants, increasing the risk of infection by respiratory viruses. Several strategies are described that could decrease these serious problems which impact increasing significantly neonatal and infant mortality rates in developing countries.

Impact of a guideline on management of children hospitalized with community-acquired pneumonia

OBJECTIVES

We sought to describe the impact a clinical practice guideline (CPG) had on antibiotic management of children hospitalized with community-acquired pneumonia (CAP).

PATIENTS AND METHODS

We conducted a retrospective study of discharged patients from a children's hospital with an ICD-9-CM code for pneumonia (480-486). Eligible patients were admitted from July 8, 2007, through July 9, 2009, 12 months before and after the CAP CPG was introduced. Three-stage least squares regression analyses were performed to examine hypothesized simultaneous relationships, including the impact of our institution\x{2019}s antimicrobial stewardship program (ASP).

RESULTS

The final analysis included 1033 patients: 530 (51%) before the CPG (pre-CPG) and 503 (49%) after the CPG (post-CPG). Pre-CPG, ceftriaxone (72%) was the most commonly prescribed antibiotic, followed by ampicillin (13%). Post-CPG, the most common antibiotic was ampicillin (63%). The effect of the CPG was associated with a 34% increase in ampicillin use (P < .001). Discharge antibiotics also changed post-CPG, showing a significant increase in amoxicillin use (P < .001) and a significant decrease in cefdinir and amoxicillin/clavulanate (P < .001), with the combined effect of the CPG and ASP leading to 12% (P < 0.001) and 16% (P < .001) reduction, respectively. Overall, treatment failure was infrequent (1.5% vs 1%).

CONCLUSIONS

A CPG and ASP led to the increase in use of ampicillin for children hospitalized with CAP. In addition, less broad-spectrum discharge antibiotics were used. Patient adverse outcomes were low, indicating that ampicillin is appropriate first-line therapy for otherwise healthy children admitted with uncomplicated CAP.

Infections, bacterial resistance, and antimicrobial stewardship: the emerging role of hospitalists

The care of patients with serious infections both within and outside healthcare settings is increasingly complicated by the high prevalence of resistant or multidrug-resistant (MDR) pathogens. Moreover, infections caused by MDR versus susceptible bacteria or other pathogens are associated with significantly higher mortality, length of hospital stay, and healthcare costs. Antimicrobial misuse or overuse is the primary driver for development of antimicrobial resistance, suggesting that better use of antimicrobials will translate into improved patient outcomes, more efficient use of hospital resources, and lowered healthcare costs. Antimicrobial stewardship refers to the various practices and procedures utilized to optimize antimicrobial use. The primary goal of antimicrobial stewardship is to improve patient outcomes and lower antimicrobial resistance and other unintended consequences of antimicrobial therapy. Secondary goals are to reduce length of hospital stays and healthcare-related costs. Hospitalists are increasingly involved in the care of hospitalized patients throughout the United States. Expertise in managing conditions requiring hospitalization, and experience in quality improvement across a wide range of clinical conditions, make hospitalists well positioned to participate in the development and implementation of hospital-based antimicrobial stewardship programs designed to improve patient outcomes, reduce antimicrobial resistance, and provide more efficient and lower-cost hospital care.

Choice and duration of antimicrobial therapy for neonatal sepsis and meningitis

Neonatal sepsis is associated with increased mortality and morbidity including neurodevelopmental impairment and prolonged hospital stay. Signs and symptoms of sepsis are nonspecific, and empiric antimicrobial therapy is promptly initiated after obtaining appropriate cultures. However, many preterm and low birth weight infants who do not have infection receive antimicrobial agents during hospital stay. Prolonged and unnecessary use of antimicrobial agents is associated with deleterious effects on the host and the environment. Traditionally, the choice of antimicrobial agents is based on the local policy, and the duration of therapy is decided by the treating physician based on clinical symptoms and blood culture results. In this paper, we discuss briefly the causative organism of neonatal sepsis in both the developed and developing countries. We review the evidence for appropriate choice of empiric antimicrobial agents and optimal duration of therapy in neonates with suspected sepsis, culture-proven sepsis, and meningitis. Moreover, there is significant similarity between the causative organisms for early- and late-onset sepsis in developing countries. The choice of antibiotic described in this paper may be more applicable in developed countries.

Deriving measures of intensive care unit antimicrobial use from computerized pharmacy data: methods, validation, and overcoming barriers

OBJECTIVE

To outline methods for deriving and validating intensive care unit (ICU) antimicrobial utilization (AU) measures from computerized data and to describe programming problems that emerged.

DESIGN

Retrospective evaluation of computerized pharmacy and administrative data.

SETTING

ICUs from 4 academic medical centers over 36 months.

INTERVENTIONS

Investigators separately developed and validated programming code to report AU measures in selected ICUs. Use of antibacterial and antifungal drugs for systemic administration was categorized and expressed as antimicrobial-days (each day that each antimicrobial drug was given to each patient) and patient-days receiving antimicrobials (each day that any antimicrobial drug was given to each patient). Monthly rates were compiled and analyzed centrally, with ICU patient-days as the denominator. Results were validated against data collected from manual review of medical records. Frequent discussion among investigators aided identification and correction of programming problems.

RESULTS

AU data were successfully programmed though a reiterative process of computer code revision. After identifying and resolving major programming errors, comparison of computerized patient-level data with data collected by manual review of medical records revealed discrepancies in antimicrobial-days and patient-days receiving antimicrobials that ranged from less than 1% to 17.7%. The hospital from which numerator data were derived from electronic records of medication administration had the least discrepant results.

CONCLUSIONS

Computerized AU measures can be derived feasibly, but threats to validity must be sought out and corrected. The magnitude of discrepancies between computerized AU data and a gold standard based on manual review of medical records varies, with electronic records of medication administration providing maximal accuracy.

Antimicrobial consumption and impact of "Reserve antibiotic indent form" in an intensive care unit

Objective:

To study the antimicrobial (AM) consumption, record the AM sensitivity pattern, and evaluate impact of “Reserve AM indent form” in the intensive care unit (ICU).

Materials and Methods:

The study was carried out in medical ICU over 4 months period at a tertiary care hospital. AM consumption was determined by defined daily dose (DDD) per 100 bed days for each month for consecutive 4 months. The average total AM consumption was calculated. The laboratory samples were processed, and the sensitivity pattern was determined. Some of the newer AM were categorised as “Reserve” and an indent form was made mandatory to be filled up prior to prescription.

Results:

The total AM consumption was 232 per 100 bed days. The commonly used AM were penicillin with β-lactamase inhibitor (21%) followed by antifungal drugs (13.4%), cephalosporins and macrolides (11.7%) each. The most common organism isolated was Acinetobacter (26.1%) followed by Candida (23.8%) and Pseudomonas (21.4%). The average occupancy index was 0.53, and the average duration of ICU stay was 6 days. The consumption of carbapenems (new AM) and antifungals decreased from 18.8/100 to 10.6/100 and 56.1/100 to 22.1/100 bed days, respectively, after the introduction of indent form.

Conclusion:

The “Reserve AM indent form” was helpful in reducing the AM consumption during the study period. The AM indent form can be used as an important tool to combat irrational use, AM resistance and can be implemented in AM stewardship programmes.

Secular trends in antibiotic use among neonates: 2001-2008

BACKGROUND

Few data exist on time trends of antibiotic consumption among neonates.

OBJECTIVES

To assess secular trends in antibiotic consumption in the context of an antibiotic policy and the effect of antibiotic use on the development of antimicrobial resistance and outcome among neonates in a single center.

METHODS

We performed a prospective cohort study between 2001 and 2008 to monitor antibiotic consumption among neonates. In parallel, we initiated a policy to shorten antibiotic therapy for clinical sepsis and for infections caused by coagulase-negative staphylococci and to discontinue preemptive treatment when blood cultures were negative. Time trend analyses for antibiotic use and mortality were performed.

RESULTS

In total, 1096 of 4075 neonates (26.7%) received 1281 courses of antibiotic treatment. Overall, days of therapy were 360 per 1000 patient-days. Days of therapy per 1000 patient-days decreased yearly by 2.8% (P < 0.001). Antibiotic-days to treat infections decreased yearly by 6.5% (P = 0.01) while antibiotic-days for preemptive treatment increased by 3.4% per year (P = 0.03). Mean treatment duration for confirmed infections decreased by 2.9% per year (P < 0.001). No significant upward trend was observed for infection-associated mortality. Of 271 detected healthcare-associated infections, 156 (57.6%) were microbiologically documented. The most frequent pathogens were coagulase-negative staphylococci (48.5%) followed by Escherichia coli (13.5%) and enterococci (9.4%). Rates for extended-spectrum beta-lactamase-producing microorganisms and methicillin-resistant Staphylococcus aureus remained low.

CONCLUSIONS

Shortening antibiotic therapy and reducing preemptive treatment resulted in a moderate reduction of antibiotic use in the neonatal intensive care unit and did not increase mortality.

Current challenges in the management of the infected patient

PURPOSE OF REVIEW

Management of hospital-associated infections (HAIs) has been made more challenging by the increasing proportion of immunocompromised or otherwise severely ill patients and increasing prevalence of antibiotic-resistant pathogens in this environment. This review examines strategies to optimize clinical outcomes and lower healthcare costs for patients with HAIs by focusing on patient-related, pathogen-related, and drug-related factors.

RECENT FINDINGS

Factors have converged to increase the risk of infection with antibiotic-resistant pathogens in the current hospital environment, including the increasing prevalence of resistant species and number of hospitalized patients with conditions increasingly susceptible to infection with drug-resistant bacteria. Although the list of bacterial pathogens associated with HAIs has been fairly constant over time, the prevalence and resistance profile of these individual species continues to evolve. Periodic antibiograms should be utilized to access local patterns of resistance within the different hospital wards. Outcomes for patients with HAIs are optimized with early empiric treatment with an appropriate regimen, selected on the basis of patient characteristics and local resistance patterns. Dosing strategies should be utilized to ensure that the efficacy of an appropriate antibiotic is optimized, by achieving the pharmacodynamic target predictive of its efficacy. Using these strategies improves quality of care and is associated with lower overall healthcare costs.

SUMMARY

Bacterial resistance is an increasing problem in the hospital environment, and has been associated with poorer clinical outcomes and elevated healthcare costs. By using patient characteristics, local antibiograms, and dosing strategies to achieve an optimal pharmacodynamic profile, early appropriate empiric therapy can be utilized to improve clinical outcomes, minimize the development of resistance, and reduce healthcare costs.

Health Care–Associated Infection in the Pediatric Intensive Care Unit

•Handwashing is the most important means of preventing nosocomial infection. Each pediatric intensive care unit should develop programs to increase compliance with hand hygiene. •Nonessential invasive devices should be removed. Establish routines that require individual patient evaluation of device use daily. •Antimicrobial stewardship aims to minimize overexposure and unnecessary use of broad-spectrum antibiotics. Antibiotic-resistant bacteria are an increasing concern as a cause of hospital-acquired infection, requiring a multipronged approach to control that includes adherence to isolation procedures, appropriate use of antibiotics, educational interventions, prescribing guidelines, and restriction of the use of some antibiotics. •A comprehensive infection prevention and control program allied with organizational quality and patient safety programs is an essential strategy for minimizing hospital-acquired infections. Critical care teams should establish strong collaborative partnerships with the infection prevention and control service. •Parents and visitors should be made partners of the infection control team to help prevent infection in their children.

Current debate on the use of antibiotic prophylaxis for caesarean section

Caesarean delivery is frequently complicated by surgical site infections, endometritis and urinary tract infection. Most surgical site infections occur after discharge from the hospital, and are increasingly being used as performance indicators. Worldwide, the rate of caesarean delivery is increasing. Evidence-based guidelines recommended the use of prophylactic antibiotics before surgical incision. An exception is made for caesarean delivery, where narrow-range antibiotics are administered after umbilical cord clamping because of putative neonatal benefit. However, recent evidence supports the use of pre-incision, broad-spectrum antibiotics, which result in a lower rate of maternal morbidity with no disadvantage to the neonate.

Variability in antibiotic use at children's hospitals

BACKGROUND

Variation in medical practice has identified opportunities for quality improvement in patient care. The degree of variation in the use of antibiotics in children's hospitals is unknown.

METHODS

We conducted a retrospective cohort study of 556,692 consecutive pediatric inpatient discharges from 40 freestanding children's hospitals between January 1, 2008, and December 31, 2008. We used the Pediatric Health Information System to acquire data on antibiotic use and clinical diagnoses.

RESULTS

Overall, 60% of the children received at least 1 antibiotic agent during their hospitalization, including >90% of patients who had surgery, underwent central venous catheter placement, had prolonged ventilation, or remained in the hospital for >14 days. Even after adjustment for both hospital- and patient-level demographic and clinical characteristics, antibiotic use varied substantially across hospitals, including both the proportion of children exposed to antibiotics (38%-72%) and the number of days children received antibiotics (368-601 antibiotic-days per 1000 patient-days). In general, hospitals that used more antibiotics also used a higher proportion of broad-spectrum antibiotics.

CONCLUSIONS

Children's hospitals vary substantially in their use of antibiotics to a degree unexplained by patient- or hospital-level factors typically associated with the need for antibiotic therapy, which reveals an opportunity to improve the use of these drugs.

Antibiotic susceptibility of intra-abdominal infection isolates from Indian hospitals during 2008

A total of 542 clinical isolates of aerobic Gram-negative bacilli from intra-abdominal infections were collected during 2008 from seven hospitals in India participating in the Study for Monitoring Antimicrobial Resistance Trends (SMART). Isolates were from various infection sources, the most common being gall bladder (30.1 %) and peritoneal fluid (31.5 %), and were mostly hospital-associated isolates (70.8 %) as compared to community-acquired (26.9 %). The most frequently isolated pathogens were Escherichia coli (62.7 %), Klebsiella pneumoniae (16.7 %) and Pseudomonas aeruginosa (5.3 %). Extended-spectrum beta-lactamase (ESBL) rates in E. coli and K. pneumoniae were very high, at 67 % and 55 %, respectively. Most isolates exhibited resistance to one or more antibiotics. The most active drugs were generally ertapenem, imipenem and amikacin. However, hospital-acquired isolates in general, as well as ESBL-positive isolates, exhibited lower susceptibilities than community-acquired isolates. Further surveillance monitoring of intra-abdominal isolates from India is recommended.

Rotation of antimicrobial therapy in the intensive care unit: impact on incidence of ventilator-associated pneumonia caused by antibiotic-resistant Gram-negative bacteria

The development of antibiotic resistance is associated with high morbidity and mortality, particularly in the intensive care unit (ICU) setting. We evaluated the effect of an antibiotic rotation programme on the incidence of ventilator-associated pneumonia (VAP) caused by antibiotic-resistant Gram-negative bacteria. We conducted a 2-year before-and-after study at two medical-surgical ICUs at two different tertiary referral hospitals. We included all mechanically ventilated patients admitted for > or =48 h who developed VAP. From 1 January through 31 December 2007, a quarterly rotation of antibiotics (piperacillin/tazobactam, fluoroquinolones, carbapenems and cefepime/ceftazidime) for the empirical treatment of VAP was implemented. We analysed the incidence of VAP and the antibiotic resistance patterns of the responsible pathogens in 2006, before (P1) and, in 2007, after (P2) the introduction of the scheduled rotation programme. Overall, there were 79 VAP episodes in P1 and 44 in P2; the mean incidence of VAP was 20.96 cases per 1,000 days of mechanical ventilation (MV) during P1 and 14.97 in P2, with no significant difference between periods on segmented regression analysis. We observed a non-significant reduction of the number of both the poly-microbial (14 [17.7%] in P1 and 5 [10.6%] in P2 [p = 0.32]) and of the antibiotic-resistant Gram-negative bacteria-related VAP (42 [45.2%] in P1 and 16 [34%] in P2 [p = 0.21]). Conversely, the number of VAP caused by Pseudomonas aeruginosa passed from 8.35 per 1,000 days of MV in P1 to 2.33 per 1,000 days of MV in P2 (p = 0.02). No difference in ICU mortality and crude in-hospital mortality between P1 and P2 was noted. Moreover, no significant change of microbial flora isolated through clinical cultures was observed. We were able to conclude that, despite global microbial flora not being affected by such a programme, antibiotic therapy rotation may reduce the incidence of VAP caused by antibiotic-resistant Gram-negative bacteria in the ICU, such as Pseudomonas aeruginosa. The application of this programme may also improve antibiotic susceptibility. However, further studies are needed to confirm our results.

Implementation of treatment guidelines to support judicious use of antibiotic therapy

BACKGROUND AND OBJECTIVE

Judicious use of antibiotics is essential considering the growth of antimicrobial resistance and escalating costs in health care. This intervention study used treatment guidelines to improve antibiotic therapy by changing prescribing practice.

METHODS

A before-after intervention study was performed in a 550-bed tertiary care teaching hospital in Switzerland, with an additional follow-up analysis 1 year later. The pre-intervention phase included chart analysis of current antibiotic use in 100 consecutive patients from the representative medical and surgical wards included in the study. Treatment guidelines were defined, taking into account published guidelines, the local antibacterial sensitivity of the pathogens, and the hospital antibiotic formulary defined by the drug and therapeutics committee. The guidelines were presented to the medical residents on a pocket card. They were informed and educated by the pharmacist (intervention). In the post-intervention phase immediately after the instruction, and in the follow-up phase 1 year later, a prospective analysis of antibiotic prescription was performed by chart review of 100 antibacterial treatments in consecutive patients to detect changes in antibiotic prescribing (treatment) and to determine whether these changes were sustained.

RESULTS

The pre-intervention review of antibiotic use showed the need for therapy improvements in urinary tract infections (UTI) and hospital-acquired pneumonia (HAP). In the post-intervention phase 100% of UTI were treated as recommended, compared to 30% before the intervention (P < 0.001). The follow-up analysis showed a decrease in guideline adherence to 39% in patients with UTI. Before implementation of the clinical guidelines, HAP was inappropriately treated like community-acquired pneumonia (CAP). Immediately after the intervention, 50% of HAP patients were treated as recommended, and 1 year later (follow-up phase) 56% of HAP patients received the recommended antibiotic medication. This change in prescription practice was significant (P < 0.05).

CONCLUSION

Antibiotic treatment guidelines for the infections most commonly occurring in hospitalized patients resulted in a significant increase in appropriate antibiotic use. The program was successful in changing prescription practice and achieved a sustained optimization of HAP therapy. Implementing, teaching and monitoring treatment guidelines can have a major impact on patient care.

Association between Asymptomatic Urinary Tract Infection and Postoperative Spine Infection in Elderly Women : A Retrospective Analysis Study

OBJECTIVE

The purpose of this study is to identify the relationship between asymptomatic urinary tract infection (aUTI) and postoperative spine infection.

METHODS

A retrospective review was done in 355 women more than 65 years old who had undergone laminectomy and/or discectomy, and spinal fusion, between January 2004 and December 2008. Previously postulated risk factors (i.e., instrumentation, diabetes, prior corticosteroid therapy, previous spinal surgery, and smoking) were investigated. Furthermore, we added aUTI that was not previously considered.

RESULTS

Among 355 patients, 42 met the criteria for aUTI (Bacteriuria >/= 10(5) CFU/mL and no associated symptoms). A postoperative spine infection was evident in 15 of 355 patients. Of the previously described risk factors, multi-levels (p < 0.05), instrumentation (p < 0.05) and diabetes (p < 0.05) were proven risk factors, whereas aUTI (p > 0.05) was not statistically significant. However, aUTI with Foley catheterization was statistically significant when Foley catheterization was added as a variable to the all existing risk factors.

CONCLUSION

aUTI is not rare in elderly women admitted to the hospital for lumbar spine surgery. The results of this study suggest that aUTI with Foley catheterization may be considered a risk factor for postoperative spine infection in elderly women. Therefore, we would consider treating aUTI before operating on elderly women who will need Foley catheterization.

Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America

Evidence-based guidelines for managing patients with intra-abdominal infection were prepared by an Expert Panel of the Surgical Infection Society and the Infectious Diseases Society of America. These updated guidelines replace those previously published in 2002 and 2003. The guidelines are intended for treating patients who either have these infections or may be at risk for them. New information, based on publications from the period 2003-2008, is incorporated into this guideline document. The panel has also added recommendations for managing intra-abdominal infection in children, particularly where such management differs from that of adults; for appendicitis in patients of all ages; and for necrotizing enterocolitis in neonates.

Antimicrobial susceptibility of Escherichia coli isolated from shrimp (Litopenaeus vannamei) and pond environment in northeastern Brazil

This study aimed to test the susceptibility of Escherichia coli strains isolated from the water, bottom sediments and individuals cultivated in shrimp farm ponds, to antibiotics belonging to different families, namely B-Lactams: Imipenem (IPM; 10 micro g), Ampicillin (AMP; 10 micro g), Cephalothin (CEP; 30 micro g), Cefoxitin (FOX; 30 micro g), Ceftriaxone (CRO; 30 micro g); Tetracycline: Tetracycline (TCY; 30 micro g); Aminoglycosides: Gentamicin (GEN; 10 micro g), Amikacin (AMK; 30 micro g); Chloramphenicol: Chloramphenicol (CHO; 30 micro g); Fluoroquinolones: Ciprofloxacin (CIP; 5 micro g); Nitrofurans: Nitrofurantoin (NIT; 300 micro g); Sulfonamides: Trimethoprim-Sulfamethoxazole (SXT; 30 micro g); Quilononas: Nalidixic Acid (NAL; 30 micro g). In the laboratory, the method of dissemination (Test Kirby-Bauer) was performed in order to fulfill the antibiogram tests. The results showed high indices of resistance to Imipenem, Cephalothin and Ampicillin. Chloramphenicol, Nitrofurantoin, Cefoxitin, Ceftiaxone and Ciprofloxacin have displayed the highest index of sensitive strains. The antibiotic resistance index (ARI) and the multiple resistance index (MAR) varied within the ranges of 0.068-0.077 and 0.15-0.39, respectively. More than 90.5% of strains of Escherichia coli showed a variety of resistance profiles to the tested antibiotics. The high indices of resistance may be a consequence of indiscriminate use of antibiotics, but also the transfer of resistance through mobile genetic elements found in shrimp farms.

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

The aim of this study was to determine the types nosocomial infections (NIs) and the risk factors for NIs in the central intensive care unit (ICU) of Trakya University Hospital. The patients admitted to the ICU were observed prospectively by the unit-directed active surveillance method based on patient and the laboratory over a 9-month-period. The samples of urine, blood, sputum or tracheal aspirate were taken from the patients on the first and the third days of their hospitalization in ICU; the patients were cultured routinely. Other samples were taken and cultured if there was suspicion of an infection. Infections were considered as ICU-associated if they developed after 48 hours of hospitalization in the unit and 5 days after discharge from the unit if the patients had been sent to a different ward in the hospital. The rate of NIs in 135 patients assigned was found to be 68%. The most common infection sites were lower respiratory tract, urinary tract, bloodstream, catheter site and surgical wound. Hospitalization in ICU for more than 6 days and colonization was found to be the main risk factor for NIs. Prolonged mechanical ventilation and tracheostomy, as well as frequently changed nasogastric catheterization, were found to be risk factors for lower respiratory tract infections. For bloodstream infections, both prolonged insertion of and frequent change of arterial catheters, and for urinary tract infections, female gender, period and repeating of urinary catheterization were risk factors. A high prevalence rate of nosocomial infections was found in this study. Invasive device use and duration of use continue to greatly influence the development of nosocomial infection in ICU. Important factors to prevent nosocomial infections are to avoid long hospitalization and unnecessary device application. Control and prevention strategies based on continuing education of healthcare workers will decrease the nosocomial infections in the intensive care unit.

Characteristics and outcomes of methicillin-resistant Staphylococcus aureus surgical-site infections in patients with cancer: a case-control study

BACKGROUND

Methicillin-resistant Staphylococcus aureus (MRSA) infections remain a significant cause of morbidity and mortality. We experienced an increased incidence of MRSA surgical-site infections (MRSA SSIs) at our institution. However, to our knowledge, no studies have evaluated the risk factors and outcomes of MRSA SSIs in cancer patients.

METHODS

We conducted a case-control study and identified all patients who had developed MRSA SSIs at our institution from July 1, 2002 to July 30, 2003, and all patients who had undergone surgery by the same surgical team during the same time period but who had not developed MRSA SSIs. Cases and controls were age-matched at 1:2 ratio.

RESULTS

The study included 29 cases and 58 controls. Mean interval between surgery and MRSA SSI onset was 17.8 days (range 3-75 days). Cases were more likely than controls to have progressive cancer (72 versus 38%), have received antibiotics (mainly quinolones) within 24 h of surgery (17 versus 2%), have had ongoing infection (10 versus 0%), and have had longer hospital and intensive care unit stays (11.0 versus 7.8 days and 3.4 versus 1.5 days) (all P < 0.05). In a multivariate logistic regression analysis, significant predictors of MRSA SSI in cancer patients were antibiotics use <24 h of surgery and progressive cancer. No surgical factors (i.e., procedure time or timing of perioperative antibiotics) were associated with increased risk of MRSA SSI.

CONCLUSIONS

Several clinical and postoperative factors were associated with increased risk of MRSA SSI in cancer patients, but antibiotic use before surgery (especially quinolones) and progressive cancer were the only independent predictors.

Antibiotic prophylaxis versus no prophylaxis for preventing infection after cesarean section

BACKGROUND

The single most important risk factor for postpartum maternal infection is cesarean section. Routine prophylaxis with antibiotics may reduce this risk and should be assessed in terms of benefits and harms.

OBJECTIVES

To assess the effects of prophylactic antibiotics compared with no prophylactic antibiotics on infectious complications in women undergoing cesarean section.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (May 2009).

SELECTION CRITERIA

Randomized controlled trials (RCTs) and quasi-RCTs comparing the effects of prophylactic antibiotics versus no treatment in women undergoing cesarean section.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction.

MAIN RESULTS

We identified 86 studies involving over 13,000 women. Prophylactic antibiotics in women undergoing cesarean section substantially reduced the incidence of febrile morbidity (average risk ratio (RR) 0.45; 95% confidence interval (CI) 0.39 to 0.51, 50 studies, 8141 women), wound infection (average RR 0.39; 95% CI 0.32 to 0.48, 77 studies, 11,961 women), endometritis (RR 0.38; 95% CI 0.34 to 0.42, 79 studies, 12,142 women) and serious maternal infectious complications (RR 0.31; 95% CI 0.19 to 0.48, 31 studies, 5047 women). No conclusions can be made about other maternal adverse effects from these studies (RR 2.43; 95% CI 1.00 to 5.90, 13 studies, 2131 women). None of the 86 studies reported infant adverse outcomes and in particular there was no assessment of infant oral thrush. There was no systematic collection of data on bacterial drug resistance. The findings were similar whether the cesarean section was elective or non elective, and whether the antibiotic was given before or after umbilical cord clamping. Overall, the methodological quality of the trials was unclear and in only a few studies was it obvious that potential other sources of bias had been adequately addressed.

AUTHORS' CONCLUSIONS

Endometritis was reduced by two thirds to three quarters and a decrease in wound infection was also identified. However, there was incomplete information collected about potential adverse effects, including the effect of antibiotics on the baby, making the assessment of overall benefits and harms complicated. Prophylactic antibiotics given to all women undergoing elective or non-elective cesarean section is clearly beneficial for women but there is uncertainty about the consequences for the baby.

WITHDRAWAN. Antibiotic prophylaxis for cesarean section

BACKGROUND

The single most important risk factor for postpartum maternal infection is cesarean delivery.

OBJECTIVES

The objective of this review was to assess the effects of prophylactic antibiotic treatment on infectious complications in women undergoing cesarean delivery.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register (January 2002) and the Cochrane Controlled Trials Register (The Cochrane Library, Issue 4, 2001).

SELECTION CRITERIA

Randomized trials comparing antibiotic prophylaxis or no treatment for both elective and non-elective cesarean section.

DATA COLLECTION AND ANALYSIS

Two reviewers assessed trial quality and extracted data.

MAIN RESULTS

Eighty-one trials were included. Use of prophylactic antibiotics in women undergoing cesarean section substantially reduced the incidence of episodes of fever, endometritis, wound infection, urinary tract infection and serious infection after cesarean section. The reduction in the risk of endometritis with antibiotics was similar across different patient groups: the relative risk (RR) for endometritis for elective cesarean section (number of women = 2037) was 0.38 (95% confidence interval (CI) 0.22 to 0.64); the RR for non-elective cesarean section (n = 2132) was 0.39 (95% CI 0.34 to 0.46); and the RR for all patients (n = 11,937) was 0.39 (95% CI 0.31 to 0.43). Wound infections were also reduced: for elective cesarean section (n = 2015) RR 0.73 (95% CI 0.53 to 0.99); for non-elective cesarean section (n = 2780) RR 0.36 95% CI 0.26 to 0.51]; and for all patients (n = 11,142) RR 0.41 (95% CI 0.29 to 0.43).

AUTHORS' CONCLUSIONS

The reduction of endometritis by two thirds to three quarters and a decrease in wound infections justifies a policy of recommending prophylactic antibiotics to women undergoing elective or non-elective cesarean section.

Diagnosis and Management of Complicated Intra-abdominal Infection in Adults and Children: Guidelines by the Surgical Infection Society and the Infectious Diseases Society of America

Evidence-based guidelines for managing patients with intra-abdominal infection were prepared by an Expert Panel of the Surgical Infection Society and the Infectious Diseases Society of America. These updated guidelines replace those previously published in 2002 and 2003. The guidelines are intended for treating patients who either have these infections or may be at risk for them. New information, based on publications from the period 2003–2008, is incorporated into this guideline document. The panel has also added recommendations for managing intra-abdominal infection in children, particularly where such management differs from that of adults; for appendicitis in patients of all ages; and for necrotizing enterocolitis in neonates.

Impact of an antimicrobial utilization program on antimicrobial use at a large teaching hospital: a randomized controlled trial

BACKGROUND

Multidisciplinary antimicrobial utilization teams (AUTs) have been proposed as a mechanism for improving antimicrobial use, but data on their efficacy remain limited.

OBJECTIVE

To determine the impact of an AUT on antimicrobial use at a teaching hospital.

DESIGN

Randomized controlled intervention trial.

SETTING

A 953-bed, public, university-affiliated, urban teaching hospital.

PATIENTS

Patients who were given selected antimicrobial agents (piperacillin-tazobactam, levofloxacin, or vancomycin) by internal medicine ward teams.

INTERVENTION

Twelve internal medicine teams were randomly assigned monthly: 6 teams to an intervention group (academic detailing by the AUT) and 6 teams to a control group that was given indication-based guidelines for prescription of broad-spectrum antimicrobials (standard of care), during a 10-month study period.

MEASUREMENTS

Proportion of appropriate empirical, definitive (therapeutic), and end (overall) antimicrobial usage.

RESULTS

A total of 784 new prescriptions of piperacillin-tazobactam, levofloxacin, and vancomycin were reviewed. The proportion of antimicrobial prescriptions written by the intervention teams that was considered to be appropriate was significantly higher than the proportion of antimicrobial prescriptions written by the control teams that was considered to be appropriate: 82% versus 73% for empirical (risk ratio [RR], 1.14; 95% confidence interval [CI], 1.04-1.24), 82% versus 43% for definitive (RR, 1.89; 95% CI, 1.53-2.33), and 94% versus 70% for end antimicrobial usage (RR, 1.34; 95% CI, 1.25-1.43). In multivariate analysis, teams that received feedback from the AUT alone (adjusted RR, 1.37; 95% CI, 1.27-1.48) or from both the AUT and the infectious diseases consultation service (adjusted RR, 2.28; 95% CI, 1.64-3.19) were significantly more likely to prescribe end antimicrobial usage appropriately, compared with control teams.

CONCLUSIONS

A multidisciplinary AUT that provides feedback to prescribing physicians was an effective method in improving antimicrobial use. Trial registration. ClinicalTrials.gov identifier: NCT00552838.

Antimicrobial stewardship program directed at broad-spectrum intravenous antibiotics prescription in a tertiary hospital

The antimicrobial stewardship program (ASP) is a major strategy to combat antimicrobial resistance and to limit its expenditure. We have improved on our existing ASP to implement a sustainable and cost-effective two-stage immediate concurrent feedback (ICF) model, in which the antimicrobial prescription is audited by two part-time infection control nurses at the first stage, followed by "physician ICF" at the second stage. In January 2005, an ASP focused on broad-spectrum intravenous antibiotics was implemented. All in-patients, except from the intensive care, bone marrow transplantation, liver transplantation, pediatric, and private units, being treated with broad-spectrum intravenous antibiotics were included. The compliance to ICF and "physician ICF", antibiotics usage density measured by expenditure and defined daily doses (DDD) were recorded and analyzed before and after the ASP. The overall conformance rate to antibiotic prescription guidelines was 79.4%, while the conformance to ICF was 83.8%. Antibiotics consumption reduced from 73.06 (baseline, year 2004) to 64.01 (year 2007) per 1,000 patient bed-day-occupancy. Our model can be easily applied even in the clinical setting of limited resources.

Delay of adequate empiric antibiotic therapy is associated with increased mortality among solid-organ transplant patients

Empiric antibiotic therapy is often prescribed prior to the availability of bacterial culture results. In some cases, the organism isolated may not be susceptible to initial empiric therapy (inadequate empiric therapy or IET). In solid-organ transplant recipients, the overall incidence and clinical importance of IET is unknown. We performed a retrospective cohort study of patients admitted from 2002 to 2004. Multiple logistic regression analyses were conducted to determine associations between potential determinants and mortality. IET was administered in 169/312 (54%) patients, with a hospital mortality rate that was significantly greater than those receiving adequate therapy (24.9% vs. 7.0%; relative risk [RR] 3.55; 95% confidence interval [CI], 1.85-6.83; p < 0.001). Regression analysis demonstrated that an increasing duration of IET (adjusted odds ratio [OR] at 24 h: 1.33; 95% CI: 1.15-1.53; p < 0.001), ICU-associated infections (adjusted OR: 6.27; 95% CI: 2.79-14.09; p < 0.001), prior antibiotic use (adjusted OR: 3.56; 95% CI: 1.51-8.41; p = 0.004) and increasing APACHE-II scores (adjusted OR: 1.26; 95% CI: 1.16-1.34; p < 0.001) were independently correlated with hospital mortality. IET is common and appears to be associated with an increased hospital mortality rate in the solid-organ transplant population.

Outcomes of early switching from intravenous to oral antibiotics on medical wards

Objectives

To evaluate outcomes following implementation of a checklist with criteria for switching from intravenous (iv) to oral antibiotics on unselected patients on two general medical wards.

Methods

During a 12 month intervention study, a printed checklist of criteria for switching on the third day of iv treatment was placed in the medical charts. The decision to switch was left to the discretion of the attending physician. Outcome parameters of a 4 month control phase before intervention were compared with the equivalent 4 month period during the intervention phase to control for seasonal confounding (before–after study; April to July of 2006 and 2007, respectively): 250 episodes (215 patients) during the intervention period were compared with the control group of 176 episodes (162 patients). The main outcome measure was the duration of iv therapy. Additionally, safety, adherence to the checklist, reasons against switching patients and antibiotic cost were analysed during the whole year of the intervention (n = 698 episodes).

Results

In 38% (246/646) of episodes of continued iv antibiotic therapy, patients met all criteria for switching to oral antibiotics on the third day, and 151/246 (61.4%) were switched. The number of days of iv antibiotic treatment were reduced by 19% (95% confidence interval 9%–29%, P = 0.001; 6.0–5.0 days in median) with no increase in complications. The main reasons against switching were persisting fever (41%, n = 187) and absence of clinical improvement (41%, n = 185).

Conclusions

On general medical wards, a checklist with bedside criteria for switching to oral antibiotics can shorten the duration of iv therapy without any negative effect on treatment outcome. The criteria were successfully applied to all patients on the wards, independently of the indication (empirical or directed treatment), the type of (presumed) infection, the underlying disease or the group of antibiotics being used.

Infection control and antibiotic stewardship practices reported by south-eastern Mediterranean hospitals collaborating in the ARMed project

The prevalence of multiply resistant organisms (MROs) reported from south-eastern Mediterranean hospitals highlights the need to identify possible contributory factors to help design control interventions. This was investigated through a structured questionnaire, which examined infection control and antibiotic stewardship practices in hospitals participating or collaborating with the Antibiotic Resistance SurveilLance & Control in the Mediterranean Region (ARMed) project. A total of 45 hospitals (78.9% of invited institutions) responded to the questionnaire; 60% indicated that they faced periods of overcrowding when available bed complement was insufficient to cope with hospital admissions and 62% reported difficulties in isolating patients with MROs due to lack of available beds. Most hospitals relied mainly on washing to achieve hand hygiene, whether by non-medicated or disinfectant soaps. Dependence on solid bars of soap (28.9%) and cloth towels (37.8%) were among the problems identified as well as inconvenient distances of sinks from patient beds (66.6%). Alcohol hand rub was the predominant hand hygiene product in only 7% of hospitals. Programmes for better antibiotic use were mostly limited in scope; 33.3% reported having antibiotic prescribing guidelines and 53.3% of hospitals fed back resistance rates to prescribers. Auditing of antibiotic consumption, whether institution- or unit-based, was carried out in 37.8% of responding hospitals. Multi-faceted approaches aimed at improving isolation of patients with MROs, increasing the emphasis on hand hygiene by encouraging greater use of alcohol hand rubs and introducing effective antibiotic stewardship programmes should be encouraged in south-eastern Mediterranean hospitals.

Future diagnostic and therapeutic approaches in surgical infections

Despite ongoing efforts to standardize therapy and improve management, the morbidity and mortality associated with surgical infections remain high. Continued innovation is required to improve outcomes further, particularly in the face of the increasing prevalence of multidrug resistant organisms. Although they remain in the experimental stages, a number of recent advances have the potential to have significant impact on the management and outcomes of surgical infections. These include novel diagnostic strategies, antimicrobials targeting microbial virulence factors, novel vaccines, and risk stratification based on genetic profiling.