Impact of Comorbidities on Hospital-Acquired Infections in a Geriatric Rehabilitation Unit: Prospective Study of 252 Patients

Drug-Drug Interactions in Nosocomial Infections: An Updated Review for Clinicians

Prevention, assessment, and identification of drug-drug interactions (DDIs) represent a challenge for healthcare professionals, especially in nosocomial settings. This narrative review aims to provide a thorough assessment of the most clinically significant DDIs for antibiotics used in healthcare-associated infections. Complex poly-pharmaceutical regimens, targeting multiple pathogens or targeting one pathogen in the presence of another comorbidity, have an increased predisposition to result in life-threatening DDIs. Recognising, assessing, and limiting DDIs in nosocomial infections offers promising opportunities for improving health outcomes. The objective of this review is to provide clinicians with practical advice to prevent or mitigate DDIs, with the aim of increasing the safety and effectiveness of therapy. DDI management is of significant importance for individualising therapy according to the patient, disease status, and associated comorbidities.

Serum Leptin Levels, Nutritional Status, and the Risk of Healthcare-Associated Infections in Hospitalized Older Adults

We aimed to determine whether serum leptin levels are predictive of the occurrence of healthcare-associated infections (HAIs) in hospitalized older patients. In a prospective cohort, 232 patients had available data for leptin and were monitored for HAIs for 3 months. Admission data included comorbidities, invasive procedures, the Mini Nutritional Assessment (MNA), BMI, leptin, albumin and C-reactive protein levels, and CD4 and CD8 T-cell counts. Multivariate logistic regression modelling was used to identify predictors of HAIs. Of the 232 patients (median age: 84.8; females: 72.4%), 89 (38.4%) experienced HAIs. The leptin level was associated with the BMI (p < 0.0001) and MNA (p < 0.0001) categories. Women who experienced HAIs had significantly lower leptin levels than those who did not (5.9 μg/L (2.6–17.7) and 11.8 (4.6–26.3), respectively; p = 0.01; odds ratio (OR) (95% confidence interval): 0.67 (0.49–0.90)); no such association was observed for men. In a multivariate analysis of the women, a lower leptin level was significantly associated with HAIs (OR = 0.70 (0.49–0.97)), independently of comorbidities, invasive medical procedures, and immune status. However, leptin was not significantly associated with HAIs after adjustments for malnutrition (p = 0.26) or albuminemia (p = 0.15)—suggesting that in older women, the association between serum leptin levels and subsequent HAIs is mediated by nutritional status.

Influencing Factors Associated with Implementation of INTERACT (Interventions to Reduce Acute Care Transfers) in VA Community Living Centers (CLCs) Using the Consolidated Framework

Our objective was to identify the influencing factors associated with the implementation of the INTERACT (Interventions to Reduce Acute Care Transfers) Quality Improvement program within a national healthcare system. INTERACT focuses on early identification and management of changes in residents' condition leading to a reduction in potentially preventable hospital transfers. The Consolidated Framework was used to evaluate implementation data from eight VA Community Living Centers. Qualitative implementation data suggest two influencing Consolidated Framework domains had a strong influence: 1) key attributes of the intervention (e.g., adaptability or complexity) and 2) internal organizational factors (e.g., culture or compatibility). Using the Consolidated Framework can assist future adaptations to this and other complex quality improvement initiatives.

Functional decline in geriatric rehabilitation ward; is it ascribable to hospital acquired infection? A prospective cohort study

BACKGROUND

In some European countries, including France, older patients with functional decline in acute units are transferred to geriatric rehabilitation units. Some patients may not benefit from their stay in a geriatric rehabilitation unit and paradoxically worsened their functional status. Previous prognostic models of functional decline are based on only baseline parameters. However, some events can occur during rehabilitation and modify the association between baseline parameters and rehabilitation performance such as heart failure episode, falls or hospital-acquired infection (HAI). The incidence of functional decline in these units and factors associated with this decline have not been clearly identified.

METHODS

We used a prospective cohort of consecutive patients aged ≥75 years admitted to a geriatric rehabilitation unit in a French university hospital. The main endpoint was functional decline defined by at least an one-point decrease in Activities of Daily Living (ADL) score during the stay. Baseline social and geriatric characteristics were recorded and comorbidities were sought by the Cumulative Illness Rating Scale for Geriatrics (CIRS-G). During follow-up, hospital-acquired infection (HAI) was recorded, as was ADL score at discharge. Multivariate logistic regression and mediation analyses were used to identify factors associated with ADL decrease.

RESULTS

Among the 252 eligible patients, 160 (median age 84 years [interquartile range (IQR) 80-88] had available ADL scores at baseline (median score 7 [IQR 4-10]) and at discharge (median 9 [6-12]). Median CIRS-G score was 11 [8-13], 23 (14%) had a pulmonary HAI; 28 (17.5%) showed functional decline. On multivariable analysis, functional decline was associated with comorbidities (global CIRS-G score, P = 0.02, CIRS-G for respiratory disease [CIRS-G-R] ≥2, P = 0.02, or psychiatric disease, P = 0.02) and albumin level < 35 g/l (p = 0.03). Significant associations were found between functional decline and CIRS-G-R (OR 3.07 [95%CI 1.27-7.41], p = 0.01), between functional decline and pulmonary HAI (OR 3.12 [1.17-8.32],p = 0.02), and between CIRS-G-R and pulmonary HAI (OR 12.9[4.4-37.7], p = 0.0001). Theses associations and the reduced effect of CIRS-G-R on functional decline after adjusting for pulmonary HAI (OR 2.26 [0.83-6.16], p = 0.11) suggested partial mediation of pulmonary HAI in the relation between CIRS-G-R and functional decline.

CONCLUSION

Baseline comorbidities were independently associated with functional decline in patients hospitalized in a geriatric rehabilitation unit. Pulmonary HAI may have mediated this association. We need to better identify patients at risk of functional decline before transfer to a rehabilitation unit and to test the implementation of modern and individual programs of rehabilitation outside the hospital for these patients.

Impact of the Physician Orders for Life-Sustaining Treatment (POLST) Program Maturity Status on the Nursing Home Resident's Place of Death

The Physician Orders for Life-Sustaining Treatment (POLST) program was developed to enhance quality of care delivered at End-of-Life (EoL). Although positive impacts of the POLST program have been identified, the association between a program maturity status and nursing home resident's likelihood of dying in their current care settings remain unanswered. This study aims to evaluate the impact of the POLST program maturity status on nursing home residents' place of death. Using multiple national-level datasets, we examined total 595,152 residents and their place of death. The result showed that the long-stay residents living in states where the program was mature status had 12% increased odds of dying in nursing homes compared that of non-conforming status. Individuals residing in states with developing program status showed 11% increase in odds of dying in nursing homes. The findings demonstrate that a well-structured and well-disseminated POLST program, combined with a continued effort to meet high standards of quality EoL care, can bring out positive health outcomes for elderly patients residing in care settings.

[Influence of nosocomial infections on activities of daily living in acute geriatric inpatients]

BACKGROUND

Nursing home residents and older hospitalized patients have a significantly higher risk to suffer from nosocomial infections (NI). It is still an unanswered question whether patients suffering from NI are at greater risk for deterioration of activities of daily living.

MATERIAL AND METHODS

In a retrospective observational study, we evaluated the prevalence of NI during hospitalization of acute geriatric inpatients of the geriatric department at Jena University Hospital by patient records. The study included data from 555 patients, hospitalized from 1 August 2011 to 31 August 2012. We included patients without acute complications and those who developed NI after the second day of hospitalization.

RESULTS

Every third patient developed a NI during the observation period. Consequently, the incidence of NI was approximately 18 patients with NI per 1000 days of hospitalization. This rate was considerably higher than the national average. The most frequent NIs were urinary tract infection, gastroenteritis and infections of the lower respiratory tract. A low value of Barthel index at admission, high multimorbidity index and transurethral indwelling catheters promoted the development of NI. An improvement in activities of daily living, assessed by mean values of the difference in the Barthel index, was significantly lower in patients who developed NI (mean value14.5 ± 16.3) than in patients who did not (mean value 18.1 ± 14.8).

CONCLUSION

Nosocomial infections were a relevant factor for deterioration of the Barthel Index, at least temporarily and NIs, in particular the combination of several NIs, jeopardized an improvement in the activities of daily living. This was particularly true for infections of the lower respiratory tract and gastroenteritis.

Deep sedation during catheter ablation for atrial fibrillation in elderly patients

BACKGROUND

Atrial fibrillation (AF) is the most common cardiac arrhythmia. AF incidence increases with age. AF ablation procedures are routinely performed under deep sedation with propofol. The purpose of the study was to evaluate if propofol deep sedation during AF ablation is safe in elderly patients.

METHODS

Four hundred one consecutive patients (mean age, 61.4 ± 11.1 years; range, 20-82; 66.3 % men) who were presented to our institution for ablation of symptomatic AF were enrolled. Patients were divided into three groups: Patients in group A were ≤50 years old; patients in group B were 51-74 years old; and patients in group C were ≥75 years old. Procedures were performed under deep sedation with propofol, midazolam, and piritramide. SaO2, electrocardiogram, arterial blood pressure, and arterial blood gas were monitored throughout the procedure. Sedation-related complications, intraprocedural complications, and other adverse events were evaluated. Fisher exact or χ (2) tests were used for comparison of adverse events and complications among groups. Analysis of variance was used to compare sedation- and procedure-related parameters.

RESULTS

Fifty-three (13.2 %) elderly patients were in group C and were compared to 73 (18.2 %) patients in group A and 275 (68.8 %) in group B. No significant differences in sedation-related or intraprocedural complications were seen (group A, 1.4 %; group B, 1.1 %; group C, 3.7 %; p = 0.336). Despite a significantly greater drop in systolic blood pressure in under sedation in group C (group A, 15.5 ± 9.5 mmHg; group B, 18.9 ± 16.3 mmHg; group C, 32.3 ± 15.5 mmHg; p < 0.001), no prolonged hypotension was observed. The rate of other adverse events (delirium, respiratory infection, renal failure) was significantly higher in group C (9.4 %), compared to group A (0 %) and group B (2.2 %; p = 0.004).

CONCLUSION

Deep sedation with propofol and midazolam during AF ablation did not result in an increased rate in sedation-related complications in elderly patients. Similarly, the rate of procedural complications was not significantly different among the study groups. The rate of respiratory infections and renal failure was significantly higher in the elderly. All adverse events were treated successfully without any remaining sequelae.